WHAM 28 AC. 44112 County Borough of West Ham ANNUAL REPORT ON THE HEALTH SERVICES FOR THE YEAR 1956 BY F. ROY DENNISON, M.D., D.P.H. Medical Officer of Health and Principal School Medical Officer Mr. Mayor, Ladies and Gentlemen, I have the honour to present my Annual Report for the year 1956. There was a further small decrease in the population which was estimated by the Registrar General as 167,000 at the mid-year. Although a slowly declining trend has been evident for some years now, it is important to keep it in perspective. The highest level reached by the returning population after the war was 173,800 in 1948 and 1949; and a sharp drop of 2,700 in the census year of 1951 suggests that this peak figure may have been a little over-estimated. At most, therefore, the fall has been about 6,800, or slightly more that four per cent, in seven years. Moreover, the optimum population assumed for planning purposes was about 165,000, so that some limited continuation in the process of population adjustment; might even be regarded as a healthy sign. The birth-rate was slightly higher than in the previous year. The death-rate. Infant mortality and maternal mortality all showed small increases which were unwelcome but not of a degree or nature to give rise to immediate concern. The outstanding experience in relation to Infectious disease was the rather disturbing increase of dysentery. This was in keeping with the national trend of recent years which has not yet been satisfactorily explained. The West Ham figures were more than double those of the previous year, largely due to two. outbreaks affecting respectively the Occupation Centre and an infants school: investigations brought to light a number of unsuspected cases outside. Fortunately, the disease is usually mild, though that may imply that some cases go unrecognised, and it seems that dysentery may be more than usually prevalent for some time to come. By contrast, the incidence of food poisoning and other bowel Infections remained low. There is little comment required on the other infectious diseases. The two cases of diphtheria occurred early in the year towards the end of the episode described in last year's Annual Report: the Borough has since remained free to the time of writing. We had a favourable experience of poliomyelitis, having only three confirmed cases and no deaths during a year when the national figures were rather high. Finally, there was a gratifying reduction in the number of cases and deaths from tuberculosis: It is to be hoped that this will become a set trend. In the other sections of the Report the Chief Public Health Inspector gives interesting accounts of the main provisions of the new Clean Air Act, 1956, (Page 19) and of some problems encountered in the operation of the Food Hygiene Regulations 1955 (Page 25 onwards). The section on the Care of Mothers and Young Children contains on page 50 a summary of an enterPrising local survey of vitamin intakes during infancy; and the results of the first full year's working of the Audiology Unit appear on the following page. The survey, in particular, was of importance in demonstrating to the staff that further adjustments in the vitamin supplements given to infants would be desirable. The most notable event in relation to the School Health Service was the closure of fyfield Residential Open Air School. This marked the culmination of many years of social progress which has led to the virtual disappearance of the physically "delicate" child. Nevertheless, the school was still serving an important purpose by affording some children a Period of relief from family tensions or other unfavourable home situations. It may not, Perhaps, have been the best possible way of meeting that need, but it cannot be entirely replaced by "convalescent" provision, and suitable alternatives on a more modest scale will soon require consideration. 1 I would like to conclude with an expression of regret for the late appearance of this report. Five vacancies occurred in senior "key" posts at a critical stage of preparation and the department naturally required time to settle down after they had been filled. However, this experience emphasised the increasing difficulty of finding time to do justice to the Annual Report. Much of the material can be gathered in the course of routine work, but it requires skill and understanding to shape it into a meaningful account of what the health services are doing, and hope to do, for the public good. This responsibility is carried by a few senior officers whose full attention is needed for the efficient operation of the services and for Judiciously adaptating them to advancing modern knowledge. We are, in fact, being faced with the choice between doing the job or writing about it. No one would wish to whittle away the Annual Report, for it is an invaluable means of communication with the Council who provide the services and the public who receive them. Indeed we would wish to explore its potentialities still further; but we have here another problem which will need early consideration. It gives me great pleasure to record once again my gratitude to the Committees for their support and to the staff for their loyal service, which made it possible to achieve so much. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, F. ROY DENNISON. Medical Officer of Health and Principal School Medical Officer. Health Department, 225, Romford Road, Forest Gate, E.7. 2 CONSTITUTION OF COMMITTEES (May, 1956 to May, 1957) The Mayor (Alderman M.J.Sullivan, J.P.,) Health Committee Chairman: Alderman E.C.Cannon, J.P. Vice-Chairman: Councillor Dr.L.Comyns, J.P. The Deputy Mayor Alderman Mrs.V.Ayres, J.P. Alderman Mrs.A.A.Barnes Alderman Mrs.E.C.Cook Alderman W.A.Glllman, J.P. Alderman Mrs.D.Parsons, M.B.E., J.P. Alderman Mrs.M.Scott, J.P. Alderman Miss D.L.Smith Councillor H.J.Bates Councillor Mrs.A.A.Gannon Councillor E.S.C.Kebbell Councillor P.M.Murphy Councillor J.C.Riley Councillor R.J.Stubbs Councillor S.W.Whitear Co-opted Members: Dr.F.Framrose, Mr.A.G.Lunt and Mr.E.H.Turner. EDUCATION COMMITTEE Chairman: Alderman Mrs.M.Scott, J.P. Vice-Chairman: The Deputy Mayor Alderman Mrs.V.Ayres, J.P. The Mayor (Alderman M.J.Sullivan, J.P.,) Alderman Mrs.A.A.Barnes Alderman S.Boyce Alderman Mrs.F.Harris Alderman C.F.Lowe, J.P., Alderman A.C.Moorey, J.P., Alderman Mrs.D.Parsons, M.B.E., J.P. Alderman D.Thorogood, J.P. Alderman F.A.Warner Councillor Dr.L.Comyns, J.P. Councillor J.Crone Councillor M.Davidson Councillor Mrs.K.Doherty Councillor A.F.G.Edwards Councillor E.G.Goodyer Councillor A.J.Hughes Councillor G.A.Macaree Councillor T.C.McMillan Councillor W.Moat Councillor J.Saunders Councillor S.W.Whitear Co-opted Members: Rev.D.Rooke, Rev,Canon P.O'Donnell, Messrs.L.J.Bandy, E.P.Bell, E.P.Hart-Wllden, F.Samuels, C.W.Thurston, H.C.Willig and Professor J.W.H.King. 3 SENIOR OFFICERS OF THE HEALTH SERVICES. MEDICAL OFFICER OF HEALTH AND PRINCIPAL SCHOOL MEDICAL OFFICER F. Roy Dennison, M.D., D.P.H. DEPUTY MEDICAL OFFICER OF HEALTH AND DEPUTY PRINCIPAL SCHOOL MEDICAL OFFICER A.P.Curran, B.Sc., M.B., Ch.B., D.P.H. (Resigned 29th February, 1956) C.H.Phillips, M.R.C.S., L.R.C.P., D.P.K. (Appointed l6th April, 1956) CHIEF ASSISTANT SCHOOL MEDICAL OFFICER. Austin Furniss, L.R.C.P., L.R.C.S., L.R.F.P.S., L.M.S.S.A., D.P.H., L.D.S. SENIOR ASSISTANT MEDICAL OFFICER, MATERNITY AND CHILD WELFARE. Miriam Florentin, M.B., Ch.B., D.P.H. SENIOR DENTAL OFFICER. S.M.Young, L.D.S., R.C.S. (Eng.) CHIEF SANITARY INSPECTOR. H.Ault, M.S.I.A. CHIEF ADMINISTRATIVE ASSISTANT. Stanley Johnson, B.A. (Admin.). SUPERINTENDENT NURSING OFFICER. Miss D.L.Fraquet, S.R.N., S.C.M., H.V's Cert., S.I's Cert. 4 STATISTICAL SUMMARY. 1956 Area of Borough 4,689 acres Population (R.G's mid-year estimate) 167,000 Live Birth 2,583 Crude birth rate (per 1,000 population) 15.46 Adjusted birth rate (per 1,000 population) 14.06 Stillbirths 58 Stillbirth rate (per 1,000 total births) 21.9 Deaths 1,769 Crude death rate (per 1,000 population) 10.59 Adjusted death rate (per 1,000 population) 13.34 Deaths of infants under 1 year 63 Infant mortality rate (deaths per 1,000 live births) 24.4 Deaths of Infants under 4 weeks of age 40 Neonatal death rate (deaths per 1,000 live births) 15.4 Maternal deaths 3 Maternal mortality rate (per 1,000 live & stillbirths) 1.14 VARIOUS DISEASES: Cases and Deaths. Cases Case rate per 1,000 population Deaths Death rate per 1,000 population Smallpox - - - _ Scarlet Fever 97 O.58 - - Diphtheria 2 0.01 - - Dysentery 285 1.71 - - Food Poisoning I4 0.08 - - Measles 550 3.29 " - Acute Poliomyelitis (paralytic) 3 0.02 " - -do- (non-paralytic) - - - - Whooping Cough 276 I.65 1 0.006 Meningococcal Infections 3 0.02 2 0.01 Typhoid and Paratyphoid Fevers 3 0.02 - - Pneumonia: Acute, primary and influenzal .84 0.50 All forms - - 105 0.63 Bronchitis - - 144 0.86 Tuberculosis: Respiratory 119 0.71 11 0.06 Other forms 11 0.06 2 0.01 Cancer - - 338 2.02 5 STATISTICS AND SOCIAL CONDITIONS OF THE AREA. SITE AND AREA. The County Borough of West Ham lies in the County of Essex within an area about 4 miles from north to south, and about 2 miles from east to west (4,689 acres). It is bounded on the north by the Boroughs of Leyton and Wanstead and Woodford, by the County Borough of East Ham on the east, on the south by the River Thames, and to the west by the Metropolitan Boroughs of Poplar and Hackney. The area is flat and low lying varying from 5 to 45 feet above sea level. POPULATION. The estimated population in 1956 was 167,000. This is a decrease of 900 on the estimated population for 1955. BIRTH RATE. Live Births. The number of live births during the year was 2,583 (males 1,297 and females 1,286). This gives a crude rate of 15.4 per 1,000 population; the same rate as for 1955. The adjusted birth rate for 1956 is 14.0 per 1,000 population which compares with a rate of 15.7 for England and Wales. Illegitimate births account for 131, or 5.7 Percent, of all live births - the rate for 1955 was 5.6 per cent. Still Births. There were 58 stillbirths (25 males and 33 females) giving a rate of 21.9 per 1,000 total births compared with a rate of 23.0 for England and Wales. DEATHS. During the year 1,769 (males 939, females 830) West Ham residents died, giving a crude death rate of 10.59 per 1,000 population. The adjusted death rate per 1,000 population is 13.34 which compares with the death rate of 11.7 England and Wales. The causes of death at different periods of life, distinguishing male and female, are given in Appendix I, page 143, INFANT MORTALITY. The deaths of children under 1 year of age numbered 63 (males 38 and females 25) giving an infant mortality of 24.4 per 1,000 live births as against 21.6 for 1955- The rate for England and Wales was 24.0. The list of causes of death can be found in Appendix I, page 143 of this report. MATERNAL MORTALITY. During the year there were 3 deaths from maternal causes, as against 1 death in 1955. The maternal mortality rate for England and Wales was O.56. See page 58 of this report for further details. ADJUSTED BIRTH AND DEATH RATES. In order to make an approximate allowance for the way in which the sex and age distribution of the local population differs from that for England and Wales as a whole, each authority is given an area comparability factor. This factor enables the local crude birth and death rates to be adjusted to compensate for these local characteristics. When so adjusted the rates are comparable with the crude rate for England and Wales or with the corresponding adjusted rate for other areas. 6 INFECTIOUS AND OTHER DISEASES. (a) Infectious Diseases. Table showing Cases of Infectious Disease Notified and Confirmed, 1956. Diseases All Age Groups Ages 1955 1956 Under 1 1-2 3-4 5-9 10-14 15-24 25 & over Deaths Smallpox - - - - - - - - - - Cholera - - - - - - - - - - Diphtheria 11 2 - - - - 2 - - - Erysipelas 18 22 - - - 1 1 - 20 - Scarlet Fever 112 97 - 5 24 53 13 2 - - Typhoid Fever 1 - - - - - - - - - Paratyphoid Fever 1 3 - - - 1 - 2 - - Typhus - - - - - - - - - - Relapsing Fever - - - - - - - - - - Plague - - - - - - - - - - Acute Poliomyelitis: (Paralytic) 15 3 1 - - 1 - 1 - - (Non-paralytic) 7 - - - - - - - - - Ophthalmia Neonatorum 1 - - - - - - - - - Malaria l 1 - - - - - - 1 - Dysentery 111 285 9 30 32 102 38 15 59 - Acute Pneumonia 94 84 7 3 1 2 - 6 66 105 (All forms) Tuberculosis: Respiratory 145 119 - 2 - 5 9 21 82 11 Meninges - 2 - 1 - - - - 1 - Other 7 9 - - - - - 2 7 2 Puerperal Pyrexia 62 19 - - - - - 8 11 - Measles 3,169 550 25 105 150 255 12 2 1 - Whooping Cough 288 276 38 59 65 111 1 - 2 1 Food Poisoning 20 14 1 1 1 6 - - 5 - Leprosy - - _ _ - - _ _ - - Meningococcal Infection 4 3 2 - 1 - - - - 2 Acute Encephalitis: Infeotive - - - - - - - - - - (Post Infectious) - 1 - - - 1 - - - - TOTALS: 4,070 1,490 83 206 274 538 76 59 254 121 7 The following table shows the age incidence and case rate per 1,000 population of Scarlet Fever, Measles and Whooping Cough. Age Scarlet Fever Measles Whooping Cough M. F. M. F. M. F. Under 1 year - - 8 17 19 19 1-4years 20 9 143 112 63 6l 5-9years 21 32 124 131 51 60 10 - 14 years 6 7 6 6 1 0 Over 15 years 1 1 1 2 0 2 48 49 282 268 134 142 97 550 276 Case Rate/1,000 population 0.58 3.29 I.65 DIPHTHERIA. Two cases occurred during the early part of the year as compared with 14- cases for 1955. MENINGOCOCCAL INFECTION. There were three cases of this disease (3 males). The age Incidence was 2 under 1 year and one aged four. There were two deaths. ACUTE POLIOMYELITIS. Three cases occurred during the year as compared with 22 In 1955.Two other suspected cases were reported but were found not to be suffering from the disease. All cases had some degree of paralysis and were admitted to hospital. There were no deaths. ERYSIPELAS. Twenty-two cases of this disease were notified, an increase of 4 over the previous year. The age and sex incidence was as follows:- Age Male Female 0-14 years 2 - 15 - 44 years 5 3 45 - 64 years 3 8 65 years & over - 1 TOTAL: 10 12 The occupational incidence for males included a factory worker, a milk roundsman, a builder's labourer, a crane driver, a machine moulder, an engineer's mate and a wood machinist; for females, a shop assistant, a cashier., a laundry hand, a bottle washer, a factory hand, a kitchen hand, and housewives. The seasonal incidence was as below. January/March 6 cases April/June 5 cases July/September 4 cases October/December 7 cases 8 PUERPERAL PYREXIA. Nineteen cases were notified during the year, a decrease of 43 as compared with 1955. Seventeen cases occurred in maternity hospitals and 2 cases at home. DYSENTERY. Two-hundred-and-eighty-five cases of Sonne Dysentery occurred during the year an increase of 174 cases over the previous year. Although the number of cases was high there were only two outbreaks which caused concern. One of these occurred in the early part of the year at the Occupation Centre Involving 20 children and 1 member of the staff at the Centre and 27 family contacts. The other outbreak occurred in October at one of the smaller infant schools in the borough. Following a report that a large number of children were absent with diarrhoea all children in the sohool were investigated. A total of 25 soholars and 4-0 family contacts were affected in this outbreak. In neither case was the source of infection established. The age and sex incidence was as follows Age March June September December Total M. F. M. F. M. F. M. F. M. F. Under 5 years 8 13 11 14 5 3 8 9 32 39 5-14 years 39 21 16 14 5 5 21 19 81 59 15 - 24- years 2 5 3 2 1 1 - 1 6 9 25 years & over 8 16 10 8 2 2 5 8 25 34 Totals: 57 55 4-0 38 13 11 34 37 144 141 FOOD POISONING. Fourteen cases of food poisoning were notified during the year. Five of these cases were associated with two outbreaks, whilst the remaining 9 cases, in spite of full investigation and inquiry including laboratory investigation of close contacts, were deemed to be isolated instances of infection for which no cause could be found. Salmonella organisms were confirmed as the infecting organisms in all cases. Annual Return of Food Poisoning Notifications. For the year 1956. Pood Poisoning Notifications (Corrected), 1. 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter TOTAL 14 Jan/March 2 April/June 5 July/September 1 Oct/December 6 2. Outbreaks due to Identified Agents Total Outbreaks 2 Total Cases 5 (Salmonella Typhi-murium 3. Outbreaks of Undiscovered Cause Total Outbreaks Total Cases If. Single Cases- - Agents Identified 9 Unknown Cause - (Salmonella Organisms) 9 TYPHOID FEVER. No cases of this disease were notified during the year. PARATYPHOID FEVER. Of the three cases notified in the Borough, one was a girl of 8 who was admitted to St.Andrew's Hospital, Bow, on 19th May as a suspected case of appendicitis. Her appendix was removed and on the 20th she started to have diarrhoea. She was transferred to Plaistow Hospital as soon as stool culture showed that she had paratyphoid. Further Investigation showed that the infecting organism was Salmonella Typhi-B, Phage type ? The other two cases notified were twin boys who contracted the disease following a visit to relatives at Bletchley. This family was admitted to hospital and Investigation showed that they were infected with paratyphoid B, Phage type Dundee. The results of Phage typing in the two boys gave the same result and it is therefore apparent that they acquired their infection at Bletchley and that no local source was Implicated. OUTBREAK OF PARATYPHOID IN A NEIGHBOURING BOROUGH. Between the 20th and 23rd May, three children in a neighbouring borough became ill and were taken to hospital where they were diagnosed as cases of paratyphoid fever. Further Investigations indicated that they had all eaten cream buns on or about the 10th May and that these had been obtained from branches of a large bakery in West Ham. Inspection of the bakery and investigation of some of the staff and of the egg products used in the preparation Of cream buns failed to disclose any cause. It was, however, ascertained that cream buns supplied to the branches which were associated with the three cases of paratyphoid had all come from a branch bakery in another Borough. It is quite likely that the infection originated at this branch. These three cases of paratyphoid fever were shown to have arisen from infection by Salmonella Typhi type Taunton. PNEUMONIA. Acute Primary and Influenzal. Eighty-four cases were notified during the year. Registered deaths from all forms of pneumonia totalled 105. The age and sex incidence of these deaths was as follows:- Age Groups Male Female Under 5 years 8 5 5 - 14 years - - 15 - 44 years 1 - 45 - 64 years 2 2 65 - 74 years 27 10 75 and over 27 23 TOTAL: 65 40 Comparison of the figures with those of 1955 shows an increase in the deaths from pneumonia In people of 65 years and over from 74 in 1955 to 87 in 1956. Pneumonia caused 5.9 per cent of deaths from all causes in the borough. 10 TUBERCULOSIS. (a) NOTIFICATIONS. One hundred and nineteen new cases of tuberculosis (75 males and 44 females) were notified during 1956, a decrease of 33 cases on the previous year's figure of 152. The age and sex distribution of the cases notified was as follows:- Age Groups Respiratory Non-respiratory M. F. M. F. 0-4 - 2 - 1 5 -14 6 8 - -' 15 - 24 11 10 1 1 25-44 24 16 2 2 45 - 64 29 8 3 - 65 years and over 5 - 1 - TOTALS: 75 44 7 4 The following table shows the totals of primary notifications of tuberculosis among children up to 5 years during the past 10 years. PRIMARY NOTIFICATIONS OF CASES OF TUBERCULOSIS. (Children under 5) Age 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 Under 1 year 1 1 2 2 2 1 1 2 - - - 1 year 3 6 7 1 3 3 2 4 2 5 21 2-4 years 7 13 10 9 5 9 7 4 1 TOTALS: 6 22 12 21 19 11 9 14 9 8 3 Sources of primary notification were from Chest Clinic, Hospitals and Sanatoria and general practitioners. The 11 non-respiratory cases notified are as follows:- Abdomen 3 Bones and Joints 3 Glands 5 (b) DEATHS. During the year 13 cases died from tuberculosis compared with 30 deaths in the previous year - this is the lowest figure ever recorded. Two of these deaths were caused by a non-respiratory form of the disease. The 11 deaths due to respiratory tuberculosis were all males. The death rate from this form of the disease was 0.06 per 1,000 of the population as compared with 0.10 for England and Wales. 11 The table below shows the age and sex distribution in respect of the deaths from tuberculosis during the year. Age Groups Respiratory Non-respiratory M. F. M. F. 0-4 1 _ - 1 5-14 - - - - 15 - 24 - - - - 25 - 44 1 - - 1 45 - 64 5 - - - 65 years and over 4 - - - TOTALS: 11 - - 2 0.73 per cent. of the deaths in the Borough from all causes was due to Tuberculosis. The incidence of notifications, and of the deaths from tuberculosis in the Borough over the past 11 years can be compared from the figures given below. The rates per 1,000 of the population in each case are also shown. (a) Notifications of Tuberculosis. Respiratory Non-respiratory Year Number Rate per 1,000 population Number Rate per 1,000 population 1946 178 1.09 23 0.14 1947 167 0.97 24 0.14 1948 192 1.10 36 0.21 1949 173 0.99 36 0.21 1950 158 0.91 20 0.12 1951 192 1.13 18 0.10 1952 130 0.76 19 0.11 1953 199 1.18 18 0.11 1954 167 0.99 22 0.13 1955 145 0.86 7 0.04 1956 119 0.71 11 0.06 (b) Deaths from Tuberculosis. Year Respiratory Non-respiratory Number Rate per 1,000 population Number Rate per 1,000 population 1946 122 0.74 10 0.06 1947 109 0.63 13 0.08 1948 95 0.55 11 0.06 1949 85 0.49 10 0.06 1950 68 0.39 6 0.03 1951 50 0.29 8 0.05 1952 39 0.23 5 0.03 1953 34 0.21 2 0.01 1954 27 0.16 1 0.006 1955 29 0.17 1 0.006 1956 11 0.06 2 0.01 12 TUBERCULOSIS 15 (b) CANCER. The number of deaths attributed to cancer was 338. The following table gives an analysis of the age and sex distribution as well as the localisation of the disease in all persons certified as dying from cancer during the year. Age Groups Malignant Neoplasms Other Malignant & Lymphatic Neoplasms TOTAL Stomach Lung & Bronchus Leukaemia & Aleukaemia Breast Uterus M. F. M. F. M. F. F. F. M. F. 0-14 _ - - _ - 1 - - - - 1 15 - 24 - - - - - 1 - - - 2 3 25 - 44 1 1 2 - - - 4 1 4 4 17 45-64 16 6 47 6 1 1 17 5 21 11 131 65 - 74 12 7 17 2 1 2 8 3 39 23 114 75 and over 13 10 8 1 - - 7 2 14 17 72 Total: 42 24 74 9 2 5 36 11 78 57 338 Nineteen per cent of the deaths from all causes in the Borough were due to cancer compared with 18 per cent for all deaths registered in England and Wales. (c) VENEREAL DISEASES. The Special Clinic for the investigation, follow-up and treatment of venereal diseases is held at Queen Mary's Hospital for the East End, Stratford, under the direction of the Consultant Venereologist, Dr.F.G.MacDonald, to whom I am indebted for the following report. (The figures in brackets are the corresponding ones for 1955). The total number of patients who attended was 530 (603). This figure includes 134 already under treatment or observation at the beginning of the year. New patients 396 (483) Total attendances 3,094 (3,036) The diagnosis was as follows:- Syphilis in the primary or secondary stage 2 (l) Syphilis in the early latent stage 1 (0) Syphilis in the later (non-infective) stages 8 (9) Congenital Syphilis 2 (5) Gonorrhoea 52 (51) Urethritis 46 (36) Other conditions 248 (347) Cases previously treated elsewhere 11 (l6) Return cases 26 (17) 14 Three (five) cases of Syphilis were treated as the result of routine ante-natal testing. Two were West Indians, the third case was a German woman married to an Englishman and was probably a Congenital infection. It will be notices that there was no evidence of any decline in the amount of Gonorrhoea and Urethritis treated in this Clinic. It is probable, too, that many cases are treated by their own Doctors. There is consequently no means of knowing the real prevalence of these conditions or of doing all that should be done to trace the sources of infection. Under "Other Conditions" are included Vaginitis and Cervicitis in women and balanitis and non-specific penile lesions in men. These conditions are,not necessarily venereal but there is usually reason for this possibility to be investigated. New cases by Area (excluding return and previously treated cases). West Ham 189 (220) East Ham 36 (38) Essex 102 (l56) Other Areas 32 (36) 15 SANITARY CIRCUMSTANCES OF THE AREA. Report of the Chief Public Health Inspector H. Ault, M.P.H.I.A. I have pleasure In submitting the Annual Report on the work of the Public Health Inspectors during the year ending 31st December, 1956. Opportunity is taken to express my appreciation of the co-operation and services rendered by the Technical and Clerical Staff. On Thursday 2nd August, 1956, the Royal Assent was given to the Sanitary Inspectors (Change of Designation) Act 1956. and Sanitary Inspectors employed by local authorities in England and Wales automatically became known as Public Health Inspectors. The career of the Bill through Parliament in its early stages was very uncertain and by the end of May the chances of it receiving a second reading in the House of Commons seemed very remote. On the 15th June, however, the Bill received an unopposed second reading, after which it made rapid progress and on l8th July passed its third reading in the Commons. The term "Sanitary Inspector" has been in use officially since 1921 when the title "inspector of Nuisances" disappeared. Generally, the new title is received with satisfaction throughout the profession although a minority do not wish to be known as public health inspectors, and it will be some time before the general public become used to the change. Some comment on items of particular interest is provided in addition to the statistical tables. The number of dwelling houses in the Borough is 41,367 and the population is 167,000. Water Supply. The Metropolitan Water Board are the Statutory Undertakers throughout the County Borough and the water has been satisfactory in quantity and quality. There is no evidence of plumbo-solvent action and no cases of contamination were reported. All the houses except two are supplied directly by pipes. In these two instances water is supplied to standpipes situated in the yards, but these properties are in confirmed Clearance Areas. Factories Act, 1937. If a factory is equipped with and uses mechanical power, the administration of the Factories Act, 1937 , is the responsibility of the Factory Inspectors of the Ministry of Labour and National Service, with the exception of the enforcement of the provision of sanitary accommodation, which is dealt with by the Public Health Inspectors. In non-mechanically operated factories, the provisions relating to cleanliness, over-crowding, temperature, ventilation and drainage of floors are dealt with by the Public Health Inspectors. In the case of factories belonging to the Crown, however, the powers and duties of district councils are administered by the Factory Inspectors and the Public Health Inspectors have no power 16 with regard to these factories. In the case of food factories, all matters relating to the inspection of food for unsoundness or disease, and the prevention of contamination, are the province of the Public Health Inspectors in any class of factory. During the year 681 visits were made to factories, and 12 written notices were served in respect of contraventions of the Act. In no case was it necessary to institute proceedings. The following table shows the work carried out during the year under this Act:FACTORIES ACT, 1937 as amended Part I of the Act 1 INSPECTIONS FOR THE PURPOSES OF PROVISIONS AS TO HEALTH MADE BY PUBLIC HEALTH INSPECTORS. Premises Number on Register Number of Inspections Written Notices Occupiers Prosecuted (i) Factories in which Sections 1,2,3,4 and 6 are to be enforced by the Local Authority 103 115 1 - (ii) Factories not included in (1) in which Section 7 is enforced by the Local Authority 899 566 11 - (iii) Other premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) - - - - TOTAL 1002 681 12 - 2. CASES IN WHICH DEFECTS WERE FOUND. (If defects are discovered at the premises on two, three or more separate occasions they should be reckoned as two, three or more "cases" .) Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector Want of cleanliness (S.l) 1 1 - 1 - Overcrowding (S.2) - - — - - Unreasonable temperature (S.3) - - — - - Inadequate ventilation (S.4) - - - - - Ineffective drainage of floors (S.6) - - - - - Sanitary Conveniences (S.7) (a) Insufficient 6 4 - 2 - (b) Unsuitable or defective 7 6 - 6 - (c) Not separate for sexes 2 2 - 1 - Other offences against the Act (not including offences relating to Outwork) - - - - - TOTAL 16 13 - 10 - 17 18 Part VIII of the Act OUTWORK Nature of Work (1) Section 110 Section 111 No. of outworkers in August list required by Section 110 (1) (c) (2) No. of cases of default in sending lists to the Council. (3) No. of prosecutions for failure to supply lists (4) No. of instances of work in unwholesome premises (5) Notices served (6) Prosecutions (7) Wearing apparel Making, etc. Cleaning and washing 164 NIL Household Linen 3 Curtains and furniture hangings l Furniture and upholstery 4 Umbrellas, etc. 2 Artificial flowers 1 Nets, other than wire nets 7 Paper bags 5 The making of boxes other receptacles parts thereof made wholly or partially of paper 27 Brush making 1 Feather sorting 2 Stuffed toys . 12 Chocolates and sweetmeats 4 Cosaques, Christmas crackers, Christmas stockings, etc. 35 Lampshades 6 TOTAL 274 Smoke Abatement. During the year the Public Health Inspectors made 211 visits to industrial premises concerning smoke emission, and to give advice on the working of the installations. The managements were obviously aware of the Increased interest in clean air, and general improvements have resulted. There is, however, still room for considerable improvement, which will no doubt follow when supplies of smokeless fuel are more readily available and obsolete plants are modernised in accordance with the provisions of the new Act. Among the large industrial firms in Custom House and Silvertown it Is gratifying to note that many continue to make use of the facilities available at the Fuel Research Station, Greenwich, for promoting smoke abatement. There has been marked improvement by firms acting on the advice given by the Research Station. On the other hand, some firms still experience difficulty in recruiting suitable stokers, particularly in the smaller plants which are hand-fired. This is due largely to full employment and the failure on the part of some firms to recognize a stoker as a skilled craftsman. Clean Air Act, 1956. The Act, which received Royal Assent on 5th July 1956, seeks to strengthen public control over air pollution. Its explanatory memorandum indicates its four main purposes. (I) to prohibit the emission of dark smoke from chimneys, railway engines and vessels, subject to certain qualifications. (ii) to prohibit the installation of new industrial furnaces unless they are capable, so far as practicable, of being operated without emitting smoke. (ill) to require that the emission of grit and dust from existing industrial furnaces shall be minimised and that new industrial furnaces burning pulverised fuel or large quantities of other solid fuel shall be provided with grit arresting equipment. (iv) to empower local authorities by order, subject to confirmation by the Minister concerned, to declare "smoke control areas", In which the emission of smoke from chimneys will constitute an offence. It is not practicable to quote the provisions of all the sections of the Act, which incidentally do not come into force until the appointed day; the following is, however, a resume of the more important sections affecting the work of the Department, Section l, Prohibition of Dark Smoke from Chimneys. This section, which prohibits the emission of dark smoke from a chimney of any building, applies to locomotives, which must incorporate "any practicable means there may be for minimising the emission of smoke". Otherwise nothing in the Act applies to a railway locomotive. The elimination of railway,smoke depends finally on electrification and the greater use of diesel oil. Legislation is unlikely to expedite it owing to the great cost and the technical details involved. The section appears to allow defences of too wide a character to be made to the offence of emitting dark smoke. The object of the section is clearly to avoid prosecution of people who inadvertently allow the offence to occur, or those who are unable to obtain the requisite fuel. 19 Section 3, Smoke from Furnaces. This section requires, subject to the provisions thereof, that all new furnaces, except domestic, be capable of being operated continuously without emitting smoke when burning fuel of a type for which they were designed. Sub-section 3 states "A furnace to which sub-section (l) of this section applies shall not be installed in a building or in any such boiler or plant as is mentioned in the said sub-section (1), unless notice of the proposal to install it has been given to the local authority, and any person who installs a furnace in contravention of this sub-section or on whose instructions a furnace is so installed shall be guilty of an offence." If the plans and specification for a new furnace are submitted to and approved by a local authority the installation will be deemed to comply with the provisions of the section, so it will not be an offence under this section if the furnace should at any time emit smoke. There is, however, nothing to preclude action for offences under the other sections of the Act. It is an offence to install a new furnace without previously notifying the local authority. It should be noted that notification is obligatory, but that the submission of plans for approval is optional. As has been stated above, in this connection the appropriate officers have considered the implications of the section and agreed that the Borough Engineer and Medical Officer of Health jointly examine all proposals submitted and report to the Health Committee accordingly. Seotion 10, Height of Chimneys. Section 10 of the Act arises directly from paragraph 106 of the Beaver Report which states:- "Special attention should be given both by the local authorities and the developers to the height of new chimneys in order to secure adequate dispersal of the dust and sulphur oxides in the chimney gases". The section provides that a Local Authority shall reject the plans for a building outside London (other than a building used, or to be used, as a residence, shop or office) unless they are satisfied that the height of a chimney shown on the plans will be sufficient to prevent, as far as practicable, the smoke, grit, dust or gases from becoming prejudicial to health, Regard must be given to (a) the purpose of the chimney, (b) the position and description of building near thereto, (c) the levels of the neighbouring ground, and (d) any other matters requiring consideration in the circumstances. Vhen considering the technical considerations governing the height of chimneys, regard should be had to the definition of "practicable" in Section 34. This reads:- "practicable" means reasonably practicable having regard, amongst other things, to local conditions and circumstances, to the financial implications and to the current state of technical knowledge, and "practicable means" includes the provision and maintenance of plant and proper use thereof. 20 The provisions of this section were considered by the appropriate officers and it was again decided that the Borough Engineer and Medical Officer of Health should jointly examine any proposals and plans submitted and report to the Works Committee accordingly. The object of examining plans for a new industrial chimney is to ensure that the discharge from it will not cause an appreciable deterioration in the health and amenities of the district around it. There are five points to be considered in detail:- (1) Down-draught. (2) Down-wash. (3) Number of chimneys serving the complete installation containing furnaces from which flue gases are to be discharged. (H) Estimated maximum concentrations at which gases and suspended fine particles from the chimney will reach the ground. (5) Estimated maximum rate of deposit on the ground of grit, soot and dust discharged from the chimney. Sections 11 to 15 Inclusive. Smoke Control Areas. Section 11 of the Act enables local authorities to establish smoke control areas by means of Orders confirmed by the Minister and Sections 12 to 15 provide for the adaptations of fireplaces in private dwellings, exchequer contributions etc. Two or more local authorities may combine for the purpose of establishing a smoke control area. The effect of a Smoke Control Order, broadly speaking, is to prohibit entirely the emission of smoke from chimneys in the area; but the provisions of the Act are flexible and allow for adaptation in local circumstances. Smoke control areas may be completely smokeless areas or they may be areas, perhaps larger in extent, in which certain classes of buildings only are subject to control, or in which certain buildings are exempt, so that the area as a whole will not be entirely smokeless. The establishment of smoke control areas will necessarily be gradual, it will need to be undertaken in stages and over a period of years. Progress will be governed by the supply of smokeless fuels, the rate at which appliances can be converted or replaced and the rate at which the Council is able to formulate and carry through Its smoke control plans. Section 16, Smoke Nuisances. This section provides that smoke other than (c) smoke emitted from a chimney of a private dwelling; or (d) dark smoke emitted from the chimney of a building or from a chimney serving the furnace of a boiler or industrial plant attached to a building or for the time being fixed to or installed on any land, shall, if it is a nuisance to the inhabitants of the neighbourhood, be deemed to be a Statutory nuisance within the meaning of Part III of the Public Health Act, 1936. 21 This section being concerned with smoke other than that from a private dwelling house and other than dark smoke omitted from a chimney will presumably cover smoke nuisances such as those covered by burning refuse in gardens and yards of factory premises. The procedure under this Section is different from that under Section 1. If smoke with which the Section is concerned is a nuisance to the inhabitants of the neighbourhood it is deemed to be a statutory nuisance under Part III of the Public Health Act, 1936 and the remedy is by service of notice as in the case of other statutory nuisances. Section 24. Building Byelaws. This section enables the Council to make building byelaws requiring the provision in new buildings of such arrangements for heating and cooking as are calculated to prevent, as far as practicable, the emission of smoke. The Minister has prepared a model byelaw which would limit the provision of cooking and heating appliances in new buildings either to such appliances for heating and cooking as are suitably designed to consume one of the following fuels; gas, electricity, gas coke or anthracite. Byelaws under this section of the Act were being considered at the end of the year, and were presented to Council and approved on 26th March, 1957. Inspection of Food and Pood Premises. In the Borough there are approximately 1750 establishments where food Is sold or prepared for sale, and during the year, 4194 visits were made to these premises. Of this number, 739 are registered under the West Ham Corporation Act 1937, Section 67, in connection with the sale of ice cream or preserved foods. The types of registered premises are as follows:- Butchers 125 Greengrocers 43 Wet and Fried Fish Shops 63 Grocers 193 Ice Cream Establishments 315 The number of licensed distributors of milk is 259 and 459 licences have been issued in relation to designated milk sold by them. One establishment is registered for the sterilisation and sale of sterilised milk. List of Food Shops This list is not complete as the Inspectors are at the time of preparation of this report carrying out a new survey of premises in their areas in view of many changes in occupation during the past few years. Dairies 14 Ice Cream Manufacturers 9 Wet Fish Shops Fried Fish Shops 70 Cafe's and Restaurants 283 Grocers 360 Greengrocers 87 Butchers 130 Bakers and Bakehouses 58 Confectioners (includes ice cream retailers) 226 Hawkers and Stalls 20 Food Manufacturers (large) 4 Public Houses and Off Licences 1302 22 Educational Activities. At the invitation of the Chairman and Executive Committee of the West Ham Clean Pood Advisory Association, Senior Public Health Inspectors gave a series of talks at Executive Committee Meetings throughout the year on various aspects of their work. The Chief Public Health Inspector and Food and Drugs Inspector, continue to act as Technical Officers to the Association. Lectures were also given to the staffs of school and day nursery kitchens and the Chief Public Health Inspector addressed a meeting of the South-West Essex Master Bakers' Association at Ilford Town Hall. Disposal of Unsound Food. Unsound food is, for the most part, removed by the Public Cleansing Department, and tipped with other refuse, but large quantities of meat and fish are sent directly to soap or fertiliser factories in the Borough. Foodstuffs Condemned During 1956 Meat 3,253 tins Cream & Milk 1,689 tins Meat 4,690 lbs. Vegetables 3,441 tins Tomatoes 39 lbs. Vegetables 2,268 lbs. Tomatoes 1,826 tins Oranges 242 cases Cheese 214 lbs. Fruit Juice 5 tins Cheese 57 boxes Cereal 13 packets Soup 145 tins Boiled Sweets 334 lbs. Fruit 6,228 tins Dried Fruit 60 lbs. Fruit (fresh) 1,288 lbs. Peanut Butter 10 lbs. Jam & Marmalade 538 jars Sandwich Cream 2 jars Fish 970 tins Ham 24 tins Fish 24½ lbs. Flour 440 lbs. Food Samples. Details of the number of samples taken during the year are contained in the Annual Report of the Public Analyst. In this report the Public Analyst gives a table of figures for the last 5 years showing the percentage of adulteration of the samples submitted to him for analysis. The percentage of adulteration for the years 1954 and 1955 showed a comparatively sharp rise over the two preceding years. This was accounted for by circumstances outside the normal rate of adulteration as commonly understood, inasmuch as during 1954 35% of the total foods found to be adulterated were oranges containing thiourea, and a further 25% of the total were sausages, containing excess of the preservatives allowed by the Preservatives Regulations, which is 450 ppm of sulphur dioxide. The 1955 figure also revealed that sausages comprised 25% of the total adulteration as in 1954 for the same reason, and 37% was accounted for by analytical confirmation of unsound foodstuffs. The figure of 1.7% for 1956 is below the average of 2.3% for the past 5 years and well below the figures for 1954 and 1955. Details of the individual unsatisfactory samples and action taken are given hereunder. 23 Sample Number Sample Analyst's Report Action Taken 78 Formal Milk Contained 3.5% added water. (Seasonal variation). 94 Formal Pork Sausages 20 ppm in excess S02 (Verbal warning). 117 Informal Ground Nutmeg Contained 2.1% sand (Formal sample factory) 177 Informal Bread (cut loaf) Mould growth (Verbal warning) 274 Informal Saveloys Contained SO2. Not declared. (Formal sample factory) 305 Informal Tincture of 0.32% deficient in iodine, (Old stock) Iodine (B.P.) 0.l6% excess potassium iodide. 106 Informal Dripping Excess of free fatty acids and (No stock left. had objectionable smell Verbal warning) There are, in addition, several items arising from the report which are also of interest:Milk. 29 samples of milk were taken in course of delivery to the schools and hospitals in the Borough, 22 for chemical analysis and 7 for bacteriological examination. All were returned as satisfactory. Sausages. A total of 25 samples of sausage were taken of which 16 were pork and 9 beef. The average meat content of the pork samples was 65.1% and that of the beef 57.8%. These averages are above the unofficial standards of 65% for pork and 50% for beef. Ice Cream. 12 samples of ice cream were purchased for chemical analysis, all of which complied with the standards laid down for this commodity by the Food Standards (ice Cream) Order 1953• The Order provides, inter alia, that ice cream must contain at least 5% fat, 10% sugar and 7½% milk solids other than fat. An analysis of the figures returned by the Analyst of the 12 samples submitted show an average of 10.9% fat, 15.2% sugar and 11.0% solids not fat, which is greatly in excess of the minimum required by the, law. The fat content in ice cream is not necessarily fat derived from milk and the use of the word "cream" is apt to be misleading. Margarine is the ingredient very largely used to supply the fat content. Cream derived from milk is sometimes used if a high class product is required. This is not in common use, however, as the cost of the completed article would be prohibitive. In addition to the above, 39 samples of ice cream were submitted to the Public Health Laboratory Service for bacteriological examination and the following results were returned:- Grade Number of Samples 1 (Good) 13 2 (Average) 13 3 (Bad) 7 4 (Very bad) 6 24 These figures do not at first sight present such a satisfactory picture as last year, when 72.7% of the samples were Grade I, but this is due to a change in sampling policy. It was decided that wrapped ice cream, being of consistently high quality, need not be sampled so frequently, and that in the event of any unsatisfactory samples being obtained every effort should be made to assist the manufacturer to improve his product. In two instances unsatisfactory samples were taken of bulk ice cream produced within the Borough, and visits were paid to the premises and the plant inspected. Samples were then taken at various points in the process of manufacture, and after several unsatisfactory results, the cause of the trouble was finally located and eliminated. This has led to the proportion of Grade I samples being small, only 33.3%, but in actual fact very useful work was done to improve standards. Iced Lollies. 4 samples of iced lollies were also submitted for bacteriological examination and all were pronounced satisfactory. Prosecutions under Food and Drugs Act, 1933. Two prosecutions were instituted under the Food and Drugs Act, 1955. In the first case a baker was fined £5 plus £2.2s.0d. costs in respect of a staple being found in a cheesecake. The second case was taken Jointly against a cafe proprietor and a manufacturer for the sale of a mouldy sausage roll. The cafe proprietor was acquitted, and the manufacturer fined £10 and 15 guineas costs. Foreign Bodies in Food. During the year enquiries were received from three other authorities regarding foodstuffs manufactured in the Borough. Two cases concerned confectionery, in one instance a screw and in the other a piece of wire having been found embedded in sweets. Inspections were made of the factory premises, and reports sent to the other authorities involved. In the third case it was alleged that a spider had been found in an ice cream cone manufactured in West Ham, but investigation showed that it must almost certainly have entered the cone after delivery to the point of sale. The Food Hygiene Regulations, 1955. These Regulations were made Jointly by the Minister of Health and the Minister of Agriculture, Fisheries and Food under Sections 13 and 123 of the Food & Drugs Act 1955- Most of the Regulations came into operation on 1st January, 1956, but certain provisions involving alterations to premises or equipment or substantial changes in existing practices were deferred until 1st July, 1956. 25 The Regulations modified and extended the hygienic requirements in Section 13 of the Food & Drugs Act, 1938. This section applied to premises, yards and forecourts, but the Regulations include a number of provisions affecting stalls and vehicles and also certain general requirements that apply wherever food is handled. Furthermore, whereas Section 13 relates to sales, actual or intended, the Regulations apply whether or not there is any question of sale. They apply to the supply of food in the course of business, which is defined so as to include canteens, clubs, schools and other institutions as well as undertakings carried on by public and local authorities. The principal extensions of the previous law relate to:- 1. specific requirements designed to prevent the contamination of food, 2. provision of sinks or other facilities for washing food or equipment, 3. the provision of a constant supply of hot water for sinks, wash basins, ete. in food premises and a supply of hot water on stalls and vehicles, 4. restriction on the preparation and packing of food in or about domestic premises, 5. the conditions under which certain foods that provide a particularly favourable medium for food poisoning organisms are to be kept in food premises, 6. a requirement to provide vehicles used for the transport of meat with duck-boards and separate receptacles for offal, and, where the vehicles are not enclosed, a covering supported by a frame or poles, 7. the circumstances in which persons carving meat are required to wear overalls and head coverings. A general provision of the Regulations includes a modification of Section 13 of the Food & Drugs Act, 1938, by Regulation 16 with the object of securing that an adequate number of wash-hand basins are provided in positions conveniently accessible to food handlers, so that frequent washing of hands will be encouraged during working hours. The Regulation is not intended to rule out the use of the wash-basins by customers as well as by food handlers. Experience in the practical application of the problems associated with the Regulations has shown that different interpretations can be placed on certain aspects of the provisions. In some cases the issues are so broad that it is almost impossible to interpret Court decisions, e.g. What is "Open Food" ? Open food is defined as food not contained in a container of such materials and so closed as to exclude all risk of contamination. The words have already produced fierce argument; the definition excludes prepacked foods but leaves a state of indecision concerning how far certain packaging can be regarded as excluding all risk of contamination, e.g. the wooden boxes of the type normally used for the packaging of peaches, apples and similar fruits. 26 It has been suggested that "open food" is any food which goes straight to the mouth without removal of either skin, peel or wrapping material. This could include unboxed apples and grapes, but not the banana or any other fruit sold with a skin to be subsequently peeled. Such a description would bring the stall of the barrow boy within the purview of the appropriate clauses. To describe "open food" as food liable to contamination by reason of not being prepacked is yet another method of giving a practical interpretation. As to whether an apple or an orange is open food or otherwise appears to depend purely upon whether they are in containers or not. The completely new definition of "Open Food" i.e. food which is not in a container of such material as to exclude all risks of contamination, may be intended to mean food which is not packeted, boxed or tinned. It aeems reasonable to consider that any food in a porous container is "open food" as there is some risk of contamination. Food therefore in ordinary porous bags is "open food". It may be argued also that oranges, bananas and eggs are examples of "open food." What is a Food for Immediate Consumption ? Section 25 of the Regulations lays down the provisions governing the temperatures at which certain foods shall be kept and in doing so mentions the term "for immediate consumption." The questions that confront Inspectors in attempting to interpret this phrase aredoes it apply only to food which is being consumed on the premises, such as a cafe, restaurant, canteen or hotel, or does it extend to fish and chips to be eaten in the street and to fruit which is eaten without prior cooking, such as apples, pears etc. Two interpretations have been suggested:- 1. that the phrase applies to all foods which can be eaten without further preparation (i.e. luncheon meat, custard pies, etc.), even if they were bought for consumption later somewhere other than on the premises where they were bought and 2. that in view of the distinction made in paragraph 2 of Regulation 3, between a retail business and one supplying food for immediate consumption, the phrase means food to be consumed on the premises where it is bought (i.e. cafes etc.). Sinks. Ever since the Food Hygiene Regulations, 1955» were first published, controversy has raged over the question of how many sinks a catering establishment should have. The Regulations state "there shall be provided and maintained in all food premises suitable and sufficient sinks or other facilities (not being wash-hand basins) for food and equipment used in the food business and there shall be provided and maintained for every such sink or other facility an adequate supply of either hot and cold water or of hot water at a suitably controlled temperature, except that a supply of cold water shall be sufficient for any sink or other facility not used for any other purpose than the washing of fish, tripe, animal casings, fruit or vegetables". 27 In addition "in all food premises, suitable and sufficient wash-hand basins for the use of all persons engaged in the handling of food on or about those premises shall be provided and maintained in a position conveniently accessible to such persons There shall be provided and maintained for every such wash-hand basin an adequate supply of hot and cold water at a suitably controlled temperature..... A supply of cold water shall be sufficient at food premises in which no open food is handled." The question arises then how many sinks should be installed in food premises. There should be in the average size food premises at least three, i.e. a washing-up sink, a vegetable sink, and a wash-hand basin. This number is usually sufficient, but where fish is washed and left in the sink until required, the sink may be out of use for other purposes for an appreciable time. The same principle applies to peeled potatoes. With the latter it is common practice to place them in enamel buckets until required for cooking. There is nothing against this practice providing the buckets are thoroughly cleansed after being used for other purposes. There is nothing in the Regulations to state that buckets, or any other containers, cannot be used to store food such as vegetables, provided that there is no risk of contamination to the food. The Inspector must decide which is suitable and sufficient in the circumstances of each individual case. There is little doubt that during 1956 a refreshing change in the public attitude towards clean food has been brought about. An interest in clean food and the Regulations generally is apparent in the number of requests that Public Health Inspectors and other health officials are receiving to give talks or answer questions on the subject. Magistrates in the Courts are also taking every opportunity to bring home the vital importance of the Regulations. One Chairman of a Bench of Magistrates after fining a man £5 for wearing a dirty overall drew the attention of traders to the maximum penalty laid down and added "it is most important that the food of the country should be properly handled". Local authorities generally are to be congratulated in having used the year to encourage both public and traders to see that the provisions of the Regulations are carried out. On the commercial side there is an increasing tendency towards the sale of prepacked foods of all types. It is stated that in 1954 only two firms were prepacking fresh meat, but by June 1956, the number had risen to nearly 2,000. Providing the actual preparation and packaging is hyglenically carried out, this represents a notable public health advance. Summary of Notices served under the Food Hygiene Regulations, 1955. During the year 3,798 visits were made to food premises, and as a result 156 Notices ware served under the Regulations in respect of contraventions found. The followingtable gives a summary of the items requiring attention. Insanitary Premises 2 Lack of Cleanliness of Equipment 45 Food Insufficiently Protected from Contamination 39 Lack of Personal Cleanliness 4 Inadequate Wrapping of Food 10 Defective Drainage Systems and Guttering 10 Insufficient or Defective Sanitary Conveniences 31 28 Inadequate Water Supply 12 Wash-basins required 65 Hot Water to be Supplied 58 Soap, towels and Nail Brush Required 6l First Aid Materials Required 48 Inadequate Facilities for Washing Pood and Equipment 16 Insufficient Lighting 6 Insufficient Ventilation 18 Lack of Cleanliness of Food Rooms 72 Accumulation of Refuse and Inadequate Bins 33 Foods not kept at Right Temperature 6 Lack of Cleanliness of Stalls 6 No Name and Address on Stall 11 Inadequate Screening of Stall 14 No waste Receptacles 6 Letters to Stallholders on General Provisions 8 No Accommodation for Clothing 32 Repairs to Walls, Floors, etc., required 30 No Smoking Notices not displayed 15 Animals in Food Rooms 14 Notices re hand washing not displayed in W.C. 16 Yard Paving requiring repair 10 Two prosecutions were instituted under the Pood Hygiene Regulations during the year. On 19th July at West Ham Magistrates' Court a stall-holder was fined £1 for failing to screen the stall in such a manner as to prevent any mud, filth or other contaminating substance being deposited on the fish displayed thereon, contrary to Regulation 27(1)(a) and also not having her name and address displayed conspicuously. On l6th August in the same Court a butcher was fined £1 for a similar offence in respect of a stall placed on the forecourt of his shop, the meat displayed thereon not being reasonably protected from contamination. Sausage Standards. The report of the Food Standards Committee has now been issued and it is to be congratulated on a sound and fair report and a masterly statement of the facts. This was an unprecendented case of the majority of trade interests pressing for the re-Imposition of a standard. The recommendations contained in the report are:- (a) A minimum standard of meat content of 65% for sausages made wholly or mainly with pork and of 50% for all other meat sausages. (b) The meat content to be restricted to bacon, ham, beef, mutton, lamb, veal, pork, edible offals (other than prohibited offals), poultry, game, rabbit, hare and venison. (c) The proportion of fat not to exceed 50% of the total meat content. (d) The standards to apply to uncooked sausages, sausage meat, skinless sausages, chipolatas and slicing sausages. (e) The sale of sub-standard sausages to be prohibited. 29 (f) The standard to apply to sausages etc.. intended for sale by catering establishments. (g) As regards the use of the description "pork sausage" and "beef sausage" the majority of the Committee consider that these descriptions should apply where at least four-fifths of the meat content consists of the named meat, but certain members of the Committee consider that they should only apply where the meat content consists of the named meat and that suitable alternative descriptions should be found for sausages containing up to one-fifth of other meat. The Committee suggest that most of the criticism concerning enforcement can be met by correct sampling to ensure that the public analyst receives an adequate representative sample. It is suggested that the original sample should be ½-lbs. and that the analyst should receive ½-lb. It is personal experience that, for factory control purposes, a 1-lb. sample is desirable. Slaughterhouses. On 1st October, 1956, new Byelaws made under Section 68 of the Food and Drugs Act, 1955, came into effect. These Byelaws did not relate to methods of slaughtering but to hygienic standards and working conditions in slaughterhouses. The following is a summary of the new conditions introduced in the Byelaws. The bringing in to a slaughterhouse of the carcase or any part of a carcase which has died or been slaughtered elsewhere than in the slaughterhouse is prohibited. An exception is made in the case of injury, illness or exposure to infection, subject to any regulations, when a slaughtered animal may be taken to a slaughterhouse after prior notification to the local authority. Lighting must be adequate for all purposes, including meat inspection, a most important point not previously recognised. External walls of a slaughterhouse which are exposed to the sun, and all refuse awaiting removal, must be treated at frequent Intervals with insecticide. The standards for employees are Improved by the regulations, that an adequate number of sanitary conveniences be provided, that there are facilities for personal washing with hot and cold water, and provision for changing and clothing storage. Facilities roust be provided for sterilising and cleansing all wiping cloths, knives, vessels and receptacles and all these articles must be kept in a sanitary condition by cleansing at frequent intervals. Suitable receptacles are to be provided for the storage of blood, with special containers used solely for blood intended for human consumption. All blood must be removed before it becomes offensive. Proper manure bins or bays must be provided and must be emptied at least every 3 days. In addition to these new requirements the sections relating to drainage, water supply and cleansing and maintenance of the slaughterhouse premises are made more specific- 30 HOUSING Unfit or "Slum" Houses. Within the Borough there are upwards of 3,000 houses which according to present day standards are classed as unfit and can quite reasonably be included in Clearance Areas, Compulsory Purchase Orders under the Housing Act 1936 and Unfitness Orders under the Planning Act, 1947, with a reasonable hope of being ultimately acquired at site value only. With the passing of the Housing Subsidies Act, 1956, which came into force on 28th March 1956, a special rate of subsidy - £22.1s.0d. - was provided for houses built to replace unfit houses and this had the effect of facilitating and encouraging the replacement of slum dwellings. What constitutes an unfit slum house and what defects does an Inspector look for when determining whether a house is sufficiently unfit to warrant inclusion in a Clearance Scheme? The Housing Repairs and Rents Act, 1954, Section 9, defines the new standard of fitness for human habitation and reads as follows:- "Standards of fitness for human habitation- (1) In determining for any purposes of the principle Act (that is the Housing Act, 1936) whether a house is unfit for habitation, regard shall be had to its condition in respect of the following matters, that is to say:- (a) repair, (b) stability, (c) freedom from damp, (d) natural lighting, (e) ventilation, (f) water supply, (g) drainage and sanitary conveniences, (h) facilities for storage, preparation and cooking of food and for the disposal of waste water; and the house shall be deemed to be unfit as aforesaid if, and only if, it is so far defective in one or more of the said matters that it is not reasonably suitable for occupation in that condition." In Circular 55/54, the Minister stated that "The purpose of the Section (9) is to make clear what are the relevant matters (and the only relevant matters), to be considered in deciding whether a house is fit or not. It is so drafted that a decision that a house is unfit may be based either upon a major defect in one of the matters listed or upon an accumulation of smaller defects in two or more of them". It is the local authority's duty to decide whether or not a house, having regard to the defects is unfit for habitation. This is decided upon by (a) an official representation; (b) a report from any of their officers; or (c) other information in their possession. It is the duty of the officers of the local authority to advise in these matters and express opinions. In coming to a decision on a matter of this kind, regard might be had to an opinion given in a recent case, that "whether a dwelling house is unfit for human habitation or not is a question of fact to be determined by the local authority in a Judicial spirit. The standard to be applied is that of the ordinary reasonable man, and it does not follow that the whole building is unfit for human habitation because certain rooms are unfit". 31 In considering the matters specified in Section 9 of the Housing Repairs and Rents Act, 1954, and in order to decide the extent to which the house is unfit under each heading the following must be taken into account. (a) Repair. External. Walls - pointing perished and open, brickwork perished. Yards paving defective, water lodging. Roofs - leaking due to loose and broken slates, flushings defective. Gutters - worn, broken and missing. Internal. Wall and ceiling plaster loose, broken or perished. Flooring rotted, broken or worm eaten. Window frames and sashes rotted, broken and ill-fitting. Sash cords broken. Doors ill-fitting, broken. Stairtreads worn and broken. Firegrates broken and obsolete. Window and door fasteners missing. (b) Stability. External walls bulging, fractured or out of plumb. Roof rafters sagging. Arches over windows fractured or out of alignment, floors, door lintels and beams DUt of level. (c) Freedom from Damp. Dampness may be rising or penetrating. Very few slum houses are free from dampness, particularly in the south of the Borough where the sites are low lying and the soil in some parts is subject to saturation by heavy tides. The absence of suitable concrete over the sites and of horizontal damp proof courses causes serious rising dampness. Dampness caused by leaking roofs, broken gutters, etc., is not usually classed under this head as it is usually attributable to disrepair. Penetrating dampness is often found as the result of the defective brickwork of an exposed party wall. (d) Natural Lighting. In considering this item, the test again is what amount of natural light a reasonable person would consider to be essential. The questions one is confronted with are - is it possible to carry out natural domestic work in a living room without the use of artificial light, or to read a newspaper without supplementary lighting. In general if the window area is at least one-tenth that of the floor area of the room, it is regarded as satisfactory and in the majority of houses in the Borough the condition is satisfied. Unfortunately in West Ham it is frequently found that houses, although having sufficient window space, are so constructed with Jutting out back additions that the lighting to the ground floor back room and the ground floor back addition room is so badly obstructed as to render the house unfit within the meaning of the section. In many cases the distances between the back additions of a row of houses are less than 10 feet, in some instances as low as 5 feet, thereby rendering it necessary to provide means of artificial lighting on most days, even in summer. Many staircases are also without means of natural lighting, a defect which might be dangerous, especially to young children and aged people. 32 (e) Ventilation. The remarks given under (d) natural lighting apply, broadly speaking, to ventilation. (f) Drainage and Sanitary Convenienses. This item, so far as slum clearance considerations are concerned, causes little or no trouble in this Borough, as all the houses are provided with drains and water closets. If it were known that the drains were defective action would probably be taken under the Public Health Act, as defective drains are regarded as serious and cannot be left in a defective condition for months or maybe years, whilst the slum clearance procedure is going through. (g) Facilities for the Storage, Preparation and Cooking of Pood and for the Disposal of Waste Water. One of the first essentials under this heading is a suitable larder ventilated directly to the external air, but this is lacking in the large majority of houses in West Ham. Other essentials, which every house in the Borough possesses, are an oven and a sink. Summary of Action Taken Under the Housing Acts, 1936-55. Areas Officially Represented. Houses Families Godfrey Street 10 10 Denmark Street 9 8 Sutton Road (3 areas) 20 26 Constance Street (3 areas) 10 14 Andrew Street and Constance Street (2 areas) 42 51 Gray street 4 6 Waddington Street (2 areas) 36 33 Naples Street (2 areas) 12 12 South Street 4 4 West Street 4 4 Mays Buildings, Chapel Street 12 11 Francis Street 13 12 Primrose Court and Cullum Street 15 7 33 Properties Recommended for Section 11 Action (Demolition). 49/50, Bridge Road 32, Crulkshank Road 36, Crescent Road 61/63, St.Georges Road 43, Victoria Dock Road 9, Clegg Street 27, 29, 31, Broad Street 4, Grove Crescent Road. (Acquired by Council) 79, Trinity Street (Acquired by Council) 58-66, Plaistow Grove 85, Maplin Road. (Undertaking from Owner) 34, Shirley Street 1, 17, 18, 20, Leabon Street 2, 4, 16, Thornham Grove Properties Recommended for Section 12 (Closing). 166, Forest Lane (First Floor) 53, Earlham Grove. (Basement) Certificates of Unfitness in Respect of Council-owned Properties. 26 and 27, Cooper Street. Demolitions Authorised in Default (Section 13). l/3, Eastwood Road 31, Browns Road 2/3, Winifred Terrace 4l, Jupp Road 58/60, Plaistow Road 19/25, Maryland Street 43, Victoria Dock Road Clearance Areas Confirmed. Capel Road and Forest Side Langthorne Street Edward Street Waddington Street Sutton Road Houses Visited. The number of houses visited on complaint and by house to house visitationwas 6,926 and, as a result of these visitations, 4,123 Notices were served and 303 summonses were issued in respect of non-compliance. 34 SUMMARY OF DEFECTS REMEDIED - 1956. Dwelling Houses. Roofs repaired 942 External walls and chimney stacks repaired 264 Gutters and spouts repaired or renewed 760 Dampness remedied 360 Internal walls and ceilings repaired 365 Rooms cleansed or redecorated 4l Doors and frames repaired or renewed 146 Windows repaired or renewed 360 Floors repaired or renewed 360 Sub floor ventilation provided or improved 40 Staircases repaired and handrails provided 84 Fireplaces and flues repaired or renewed 284 Cooking stoves repaired or renewed 50 Wash coppers repaired or renewed 6 Sinks and washbasins provided or renewed 24 Waste pipes repaired or renewed 140 Food stores provided or improved 1 Water supply improved or reinstated 166 Water closet walls, etc. cleansed 8 Water closet pans cleansed 4 Water closet pans repaired or renewed 122 Water closet cisterns repaired or renewed 170 Water closet structures repaired or rebuilt 45 Water closet flush pipe Joints repaired 128 Additional water closets provided 1 General Environmental Public Health. Drains cleansed from obstruction 114 Drains repaired or renewed 193 New drains provided 3 Inspection chambers repaired 5 New inspection chambers provided 1 Soil pipes and vent shafts repaired 97 Water closets repaired 50 Water closets cleansed 4 Additional water closets provided 2 Stables, Manure Pits, repaired or renewed 1 Animal nuisances abated 2 Offensive accumulations removed 15 Yards cleansed or repaired 15 Smoke nuisances abated 2 35 Dustbins. The position in the Borough with regard to dustbins is now much more satisfactory than it was prior to the inauguration of the Council's rental scheme, when owners and occupiers of houses were responsible for providing a suitable dustbin for each occupied dwelling. Then numerous owners and occupiers did not replace worn-out dustbins unless required to do so by Statutory Notice, and even then it was often found necessary to supply a dustbin in default and recover the cost. The present position is that 29,500 householders have now enrolled in the Council's Rental Scheme (out of a total of about 38,000) and for the sum of 5/- per year hire fee they are supplied with a regulation size British Standard Specification dustbin. These figures are, of course, exclusive of Council owned properties. A number of persons do, however, omit to renew the 5/- hire fee and in these instances the Borough Engineer after attempting to recover the money, collects the dustbin from the dwelling and notifies the Health Department that the house is without a dustbin. The number notified during 1956 was 54. On receipt of these notifications the Public Health Inspector visits the house and attempts to persuade the person responsible for providing the bin, either to pay the 5/- or to provide a suitable dustbin themselves. If the dustbin is not then provided, the matter is reported to the Health Committee, with a recommendation that a Statutory Notice be served, the dustbin supplied in default and the costs recovered. During 1956 it Was found necessary on only 7 occasions to report these defaulters to the Health Committee. The price of a dustbin at the present time may vary from £1 to £2 according to the size and quality of the receptacle. It is, therefore, not surprising that there have been numerous differences of opinion as to landlords and tenants responsibility for the supply of dustbins. The law on the subject is found in the Public Health Act, 1936, Section 75, and states:- (l) "A local authority who, as respects their district or any part thereof, have undertaken the removal of house refuse may by notice require the owner or occuplor of any building within the district, or, as the case may be, within that part of the district, to provide such number of covered dustbins for the reception of house refuse of such material, size and construction as the authority may approve. Any person aggrieved by a requirement of the local authority under this sub-section may appeal to a Court of Summary Jurisdiction". The question arises then on whom shall the notice be served, the owner or the occupier? The conflicting decisions of many Courts throughout the country leaves one in a state of bewilderment. In West Ham, when confronted with this problem, we try to ascertain who is receiving the greatest financial benefit from the letting, the owner or the tenant. Generally speaking, if the owner is in receipt of a rental equal to the economic rental, which is invariably a few shillings above the ordinary controlled rental, the notice is served on him, but where the tenant is paying only the nominal controlled rent, the notice is served on the tenant. Frequently the tenant receives additional financial benefit by subletting one or two rooms in the house, often without the landlord's knowledge, and in these cases also, the notice is served on the tenant. The particulars ascertained by the Public Health Inspectors when investigating this point are very thorough and it is pleasing to note that whilst a large number of local authorities have been faced with Court appeals under this Section, no such appeals have been lodged against the West Ham Council. 36 Caravan Dwellers in the Borough. During the past few years a great deal has been said about the people who station their caravans on sites in the Borough. These sites are usually the Rathbone Street area, land known as Vernons Fields, adjoining King George Avenue, and the land adjoining the roadside on the Beckton by-pass near to the East Ham boundary. One hears such remarks as "Why don't the Council do something about it?" and "The whole site is unhealthy and a nuisance and the Health Department does nothing about it." The position is that the Health Department and the Public Health Inspectors in particular are most concerned about the problem and spend a great deal of tine trying to persuade the caravan dwellers to move on and not to return. Since March 1953, 2,126 visits have been made to these sites and 133 summonses issued as a result. The persons who occupy the caravans, apart from the genuine showmen who usually occupy the Rathbone Street site, are of the gypsy type and have no permanent residence. During the spring, summer and autumn they spend their time in the adjoining counties planting peas and potatoes, attending fairs, and in fruit and hop-picking, and pull on to sites in West Ham during the winter months hoping to remain there until the spring. They appear to exist solely by selling clothes pegs and artificial flowers from door to door. The genuine showmen usually occupy well-equipped modern caravans, are provided with portable sanitation, and one has little fault to find with them in this respect. They do, however, encourage other caravan dwellers on to the sites and, if not made to move on, a large colony is likely to be formed. Such colonies may consist, in addition to the ordinary gypsy caravan, of old bus bodies, converted pantechnicons and other make-shifts. The legal provisions applicable to the sites in West Ham are the Public Health Act 1936, Sections 268/269, and the Bye-laws for the Good Rule and Government of the Borough of West Ham. The Public Health Act 1936, Sections 268/269 provide, briefly, as follows:- 1. Where land is used as a site for movable dwellings for more than 42 consecutive days or for 60 days in any consecutive twelve months, the owner is required to obtain a licence from the Local Authority for suoh use of the land. 2. Where the owner of a movable structure desires to place it for similar periods on land not licensed under (1) he is required to obtain a licence to rest, station and use such particular movable dwelling from the Local Authority. 3. The Local Authority when granting licences under (1) or (2) may attach such conditions as they think fit. There is a right of appeal against refusal or against the conditions attached. Suoh structures, although licensed, must also comply with Bye-laws relating to tents, vans and sheds if in force in the district. Section 269 does not apply to:- 1. Structures to which the building bye-laws apply, 2. (a) movable dwellings used in connection with a dwelling-house, (b) movable dwellings used by travelling shows etc., (c) organisations using movable dwellings to whom the Minister has granted Certificates of Exemption. 37 The Bye-laws for the Good Rule and Government of West Ham provide 1. An owner of land shall not cause or suffer any such land within two hundred yards of any street or of any dwelling house to be occupied by any tent dweller, squatter, gypsy or other person dwelling in a tent or van, or other similar structure. 2. A tent dweller, squatter or gypsy or other person shall not use as a dwelling place any tent or van, or other similar structure, placed on any land situated within two hundred yards of any street or of any dwelling house. Immediately it is known that caravan dwellers have drawn on to a site the Inspector visits and takes the names of the occupiers and on return to the office reports the matter for a summons under the above Bye-laws. This action invariably has the desired effect and the caravans usually move out of the Borough, but those who do not do so are brought before the Court and fined, the maximum being £5. In the case of caravan dwellers, other than showmen, who remain on a site for more than 42 consecutive days, an additional summons is applied under Section 269 of the Public Health Act 1936, and the occupiers are liable to a maximum fine of £5 and to a further fine of £2 for each day on which the offence continues after conviction therefor. The question of fencing the Rathbone Street and Vernons Field sites has been considered and found to be impracticable at the present time. In the case of Rathbone Street, whilst the Council own several pieces of the land the position will not be satisfactory until the redevelopment of the immediate neighbourhood has taken place. It is hoped that this development will commence within the next 3 years. An estimate of the cost of fencing Vernons Field was found to be prohibitive, for apart from the Initial cost the risk of damage is very great. Samples of Water from Swimming Baths. During the summer months 8 samples of water were taken for bacteriological and chemical examination from the swimming baths in the Borough as follows:- Beckton Road Lido 2 Rcraford Road 3 Balaam Street 3 and in all cases the samples were found to be of excellent quality and free from any harmful bacteria. The method of purification of the swimming bath water is by the closed circulation filtration system and it is sterilised by chlorine. Water drawn from the pools is pumped through the filter and returned to the pools at the shallow ends. Before passing through the filter the chemical coagulant, sulphate of alumina, is added, which has the effect of binding the impurities together, and forms the gelatinous bed which is the real filtering media. On the water leaving the filters, the chlorine sterilising agent is added. In addition to the samples taken by the Public Health Inspectors, the Baths Superintendent frequently tests the water to ensure its cleanliness. 38 Report of the Deputy Chief Public Health Inspector, E.R.H.Hodge, M.R.S.H., M.P.H.I.A. Rodent Control, Disinfection & Disinfestation Section The work of the Rodent Control Section has shown much the same pattern as in past years. Surface infestations have been treated by poisoning off, and suspected defective drainage systems have been reported to the Public Health Inspectors, who in turn have caused the defective systems to be remedied. There in no doubt that the use of Warfarin Is most effective and in most cases ensures a complete kill. The numbers of drain tests (795) gives some indication of the large number of drains suspected by the operatives to be defective and referred by them to the Public Health Inspectors for investigation. As a result of these tests, 194 notices were served under Section 24 of the Public Health Act, 1936, (for repair/relaying of sewers) and 286 under Section 4l of the West Ham Corporation Act, 1893 (for the repair/relaying of private drains). The rats were thus contained within the drainage systems, there to be dealt with during the bi-annual treatment of sewers by the Borough Engineer's Department. There is, of course, the possibility of the rats breaking out at some other defective point. In due course the defect would be found by further rat infestation and the drain repaired. It is hoped that by this means the majority of defective drains will have been discovered and repaired during the next five years. Whilst the number of premises infested by rats shows a satisfying decline, the number of properties infested by mice remains more or less static, and on enquiring from the Ministry, neighbouring authorities and private firms, it is found that this picture prevails practically throughout the country. An outbreak of dermatitis occurred in January, when three of the operatives found that their faces became affectod after using certain insecticides and disinfectants. Complaints had been made in the weeks previous, and protective masks and hoods were ordered immediately. There was, however, a delay of some weeks before the articles were received, by which time the dermatitis had become more pronounced. Following the use of the protective masks etc., the inflammation was markedly reduced. Tests were carried out at the London Hospital, the results of which were given to the Medical Officer of Health and a report was made to the Committee. In two cases at least it is thought that the dermatitis resulted from either prolonged and extensive exposure to disinfectant during three days of spraying or the inadvertent use of disinfectant in a higher concentration than usual. It is satisfactory to note, however, that since the condition cleared up, none of the operatives have complained of or have shown any further symptoms, and are now using all the insecticides etc., as before. As a precautionary measure, however, the use of protective clothing and masks is insisted upon. 39 Of 17 Intimation Notices served under Section 4 of the Prevention of Damage by Pests Act, 1949, in only two cases was it found necessary to serve Statutory Notices. Investigational visits to premises Operational visits to premises Houses 1,479 6,116 Factories 163 350 Shops 210 335 Other business premises 107 156 Bomb sites, tips, allotments and ditches 94 151 Schools 44 255 Corporation property 73 156 Hospitals 15 77 Club 1 7 Church Halls 2 13 Churches 2 10 2,190 7,626 Resulting from the above investigational visits, 680 premises were found to be Infested with rats, and 664 infested with mice. DISINFESTATIONS - VERMIN Houses 503 323 Factories 18 4 Shops 16 5 Other business premises 32 18 Bomb-sites, tips, allotments and ditches 1 - Schools 17 9 Corporation property 11 8 Hospitals 41 21 639 388 DISINFECTIONS Houses 8 8 Factories - - Hospitals 7 7 Emergency Water Supply Tanks 25 10 40 25 School Plimsolls 205. 40 ANNUAL REPORT OF THE PUBLIC ANALYST FOR 1956. During the year 411 samples were examined under the Food and Drugs Act, Of these 85 were formal and 326 informal samples. All samples were submitted by the Inspectors. Seven samples were found to be adulterated or otherwise unsatisfactory. Two were formal and five informal samples. The adulteration was at the rate of 1.7 per cent. The adulteration in the Borough for the past five years was as follows:YEAR NUMBER OF SAMPLES PERCENTAGE ADULTERATION 1956 411 1.7 1955 502 3.2 1954 502 4.0 1953 501 1.4 1952 502 1.0 Average 484 2.3 Seventy-five samples of milk were examined, fifty formal and twenty-five informal. One sample of milk was found to be adulterated, and was in fact deficient in nonfatty solids. Investigation showed that the milk had not been adulterated in the generally accepted sense, but that the deficiency was due to natural seasonal changes in the composition of fresh milk, there having been no addition of water as might otherwise have been expected. The milk adulteration in the Borough for the past five years was as follows:- YEAR NUMBER OF SAMPLES PERCENTAGE ADULTERATION 1956 75 1.3 1955 96 1.0 1954 105 0.0 1953 108 0.9 1952 101 0.0 Average 97 0.6 Condensed Milk One full-cream and three machine skimmed milks were examined. All these were informal and complied with the Regulations. Dried Milk One informal sample of skimmed milk was examined and found to be satisfactory. 41 Ice Cream Two samples were examined, one formal and one informal. Both were satisfactory. Ice Lollies Eleven informal samples were examined for metallic contamination. All were reported as being satisfactory. Drugs Twenty-one informal samples were examined. One sample of Tincture of Iodine failed to satisfy the B.P. standard. Preservatives There were two contraventions of the Preservatives Regulations. One of these was a sample of sausages which contained excess of sulphur dioxide and the other a sample of saveloys which contained undeclared preservative. Fertilisers & Feeding Stuffs Act Three official samples of fertiliser were examined. One of these was unsatisfactory. Eleven feedingstuffs, nine official and two unofficial, were examined. One was unsatisfactory. In addition to the above, the following samples were also examined:- For the Public Health Department 3 Swimming bath waters. 1 Water. 1 Substance from gully. 1 Bread. For the Borough Engineer's Department 30 Effluents. 12 Samples of soil and ground water. 1 Subsoil water. 1 River Water. For the Borough Architect!s Department 1 Ground water. For the Chief Education Officer 6 Liquid detergents 42 SAMPLING OF FOOD AND DRUGS Heat Treated Milk The Milk (Special Designation) (Pasteurised and Sterilised Milk) Regulations 1949 to 1953:- Particulars are given below regarding the various types of heat treated milk which were sampled during the year and submitted to the appropriate tests. Type of Milk Number of samples Results of Examination Phosphatase Test Methylene Blue Test Turbidity Test Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory Pasteurised 21 21 - 21 - - - Sterilised 17 - - - - 17 - Tuberculin Tested (Pasteurised) 11 11 - 11 - - - Tuberculin Tested (Sterilised) - - - - - - - Total 49 32 - 32 - 17 - FERTILISERS & FEEDINGSTUFFS ACT, 1926 Particulars are given below of the samples taken during the year:- Type of Sample No. of samples taken Analysis agreed Analysis disagreed Fertilisers. Official 3 2 1 Unofficial - - - Feedingstuffs. Official 11 10 1 Unofficial - - - Total 14 12 2 In the two cases of disagreement with the manufacturer's declared analysis, details were as follows- A sample of a general fertilizer was found on analysis to have nitrogen, potash and Phosphate slightly in excess of the amounts declared by the manufacturer. Investigation showed that this was very old stock which had been stored by the retailer for about six years, with consequent chemical change. A sample of Intensive Growers Mash had a protein content in excess of the declared amount, and a warning letter was sent to the manufacturer. 43 RAG FLOCK AND OTHER PILLING MATERIALS ACT, 1951. Six rag flock samples were examined - all were satisfactory. Summary of Public Health Inspectors' Work For the period from 1st January, 1956 to 31st December, 1956. Visits to private houses following complaints 6,926 House to house inspections under Public Health or Housing Acts 677 Inspections under the Housing Act, 1936. Closing, demolition or Repair (Sections 9, 11 & 12) 277 Inspections under the Housing Act, 1936, re Clearance Areas (Section 25) 597 Initial Survey inspections under the Housing Repairs & Rents Act, 1954 35 Inspections re overcrowding 241 Inspections re advances by Local Authority under Housing Act, 1949 137 Inspections re issue and revocation of Certificates of Disrepair 143 Certificates of Disrepair issued 4l Certificates of Disrepair revoked 30 Inspections following infectious disease 1,6l8 Visits to filthy and verminous premises 199 Smoke observations and visits re smoke nuisances 211 Visits re offensive trades 93 Visits to factories (mechanical) 566 Visits to factories (non-mechanical) 115 Visits to workplaces and outworkers premises 573 Inspections of watercourses, ditches, etc. 42 Inspections of Hairdressers and Barbers premises 37 Inspections under Prevention of Damage by Pests Act 233 Visits under Bye-laws - re tents, vans and sheds 1,271 Visits under Pharmacy and Poisons Act 21 Visits to places of public amusement 48 Visits under Shops Act, 1950 318 Visits to Bakers and Bakehouses 224 Visits to Butchers 375 Visits to kitchens of Canteens, Cafes and Restaurants 857 Visits to Licensed Premises 88 Visits to Fish Shops 75 Visits to Fried Fish Shops 55 Visits to Retail Milk Distributors 384 Visits to Ice Cream Manufacturers and Dealers 186 Visits to registered premises for storage of food 112 Visits to registered premises for preparation of foodstuffs 137 Visits to hawkers of food 113 Visits to street markets 410 Visits to slaughterhouses 109 Visits to provision shops 593 Visits to greengrocers 80 Visits to condemn unsound food 505 Reinspections 12,585 Drainage Inspections 5,645 Drain tests by Public Health Inspectors 461 Drain tests by Borough Engineer's staff 334 Miscellaneous Interviews 1,076 Miscellaneous visits l,l09 44 NATIONAL HEALTH SERVICE ACT, 1946. SECTION 22: CARE OF MOTHERS AND YOUNG CHILDREN. EXPECTANT AND NURSING MOTHERS Facilities provided for Ante-Natal and Post-Natal care were continued with ten weekly combined ante-natal and post-natal sessions at the Municipal Centres, and one at the South West Ham Health Society's Clinic. The clinic held in the Silvertown area is now combined with the Child Welfare session. Mothers attend by appointment and in each case the medical examinations are undertaken by one of the Council's medical officers. The municipal mldwives conduct most of the examinations of their patients at the Maternity and Child Welfare Centres, at the same sessions as the ante-natal clinics conducted by the medical officer, but in an adjacent room. This has fostered close cooperation between the midwives (and their pupils) the doctors, and the health visitors who also have duties at the ante-natal clinics. Early in the year agreement was reached with the Medical Liaison, Local Obstetric and Local Medical Committees on an arrangement whereby any doctor who had agreed to give maternity medical services to a mother, would have the opportunity of examining her in the presence of the midwife, on at least two occasions. The midwife was given the responsibility of contacting the doctor as early as possible in each individual case, in order to arrange for these Joint examinations, and to decide whether they should be held at the municipal clinic or at the doctor's surgery. In addition, in order to make it clear to the general practitioner that the services of the local authority were available for his maternity patients, it was agreed that the card which is sent by the general practitioner to the midwife (when he has booked a patient for maternity medical servioes) should be amended to include a section in which the doctor might indicate whether he wished his patient to be offered facilities for blood test, chest x-ray, training in relaxation, or teaching in mothercraft at the local clinic. A number of doctors have availed themselves of these arrangements which have fostered personal contact between midwife and doctor. In particular, there is considerable advantage to the patient in this joint examination in which patient, midwife and doctor may exchange views and Information, without the formality of written communication. Arrangements for women who book domiciliary midwives from the Essex County Council Service, based on the Lady Rayleigh Training Home in Leyton, include attendance at the municipal clinics for some of their medical examinations. Patients requiring specialist advice are usually referred to the consultant at one of the maternity units in the borough, while those wishing or requiring a hospital bed are referred to the hospital of their choice. One thousand three hundred and forty-one expectant mothers have made a botal of 6,918 attendances at the ante-natal clinics during the year. Two hundred and twenty seven attended for examination during the post-natal period and made a total of 266 attendances. This is 72% of the total of 340 domiciliary confinements, but does not include post-natal examinations undertaken by general practitioners. 45 Blood tests are carried out on all patients attending these clinics and include a Kahn, Rhesus factor, blood group and Haemoglobin estimation In every case. Any tendency to anaemia is kept under careful observation, (which includes further blood examinations) because anaemia in the expectant mother may have serious implications for both mother and baby. Mothers are encouraged to take iron regularly during pregnancy, particularly during the last three months. Chest X-rays. Provision for chest x-ray for all expectant mothers, which was started in 1953, has continued throughout the year. Every expectant mother attending the ante-natal clinic, if she has not already had a chest x-ray during her present pregnancy, is offered an appointment at a special session of the Mass Radiography Unit which is held at one of the Welfare Centres. Unfortunately, under present circumstances, the sessions can only be held infrequently, which probably accounts for the rather low attendances. Mothers booked for confinement at Plaistow Maternity Hospital and those attending the Essex County Council Leyton Health Area Clinics arc also invited to these x-ray sessions. Unmarried Mothers. Close and friendly co-operation has been maintained with the Moral Welfare Worker employed by the Chelmsford Diocesan Moral Welfare Association, and with the Committee and the Superintendent of St. Agatha's Hostel which is situated in the borough. Miss McCleod, who had worked in the dual capaoity of Superintendent of the hostel and Moral Welfare Worker for a very extensive area, which included West Ham, retired during the year after many years devoted service, and we would like to place on record our appreciation of her work. No permanent Superintendent has yet been appointed to St. Agatha's but when she takes up her duties they will be concerned entirely with the hostel. The social work for unmarried mothers and their babies is now undertaken by Miss Treacher, on behalf of the Moral Welfare Association. Her office is in Ilford, but she is available to interview in West Ham those mothers who find this more convenient. We are pleased to welcome Miss Treacher as a colleague. The close integration of her work with the work of the Health Department, which she has so successfully achieved, will be very helpful to the mothers concerned. CHILD WELFARE. Premature Infants. Prematurity remains our greatest cause of infant death and the prevention of premature births and of the death of premature infants are two of our most pressing problems. They are problems which are not confined to this area, but are national and indeed world wide. The number of premature births was the same as last year, and the proportion remains at 7.3% of total births. Out of a total of 63 deaths of infants under 1 year, 25 (39%) oocurred in premature infants who didd within the first month of life. As analysis of causes of these 25 deaths is as follows:- Prematurity 17 Prematurity associated with pneumonia 2 Prematurity associated with Cerebral Haemorrhage and Exomphalos 1 Prematurity associated with Meconium Iieus 1 Prematurity associated with Atelectasis 3 Prematurity associated with respiratory failure 1 22 46 Place of Birth and Deaths under 1 month of Premature Infants. Number of Infants Number died within 24 hours Number died within 28 days Number Survived 28 days Born & nursed at home 13 - - 13 Born & nursed in nursing home 1 - - 1 Born & nursed in hospital 175 8 16 151 Born at home & transferred to hospital 1 - 1 - TOTAL: 190 8 17 165 Child Welfare Sessions. The needs of the area have been met by a total of 17 sessions per week held at the Municipal Centres and at the South West Ham Child Welfare Centre. In the Silvertown area the Child Welfare Session is combined with ante-natal and immunisation clinics, as it has been found that this is sufficient to meet the needs, Fourteen children and 3 expectant mothers resident in neighbouring areas attended West Ham clinics, and 6 children resident in West Ham are known to have attended clinics in other areas. Toddlers' Clinics. In addition to the 17 sessions mentioned above an average of 4 special toddlers' clinics were held weekly. At these, 2,886 children attended in response to the 7,994 invitations to come for examination on their 2nd, 3rd or 4th birthday. There were 2,446 children whose general condition was regarded as good, 411 children in whom it was recorded as fair, and 29 in whom it was recorded as poor. In the same group of children there were 2,663 whose cleanliness of body and clothing was recorded as good, 214 in whom it was found to be not entirely satisfactory, and 9 in whom it was poor. There were 2 children who were found to have infestation of the head, and 2 with infestation of the body. Defects or deviations from normality found in the same group of children are shown below. The Table includes conditions observed by the doctor or described by the mother and recorded at the time of the examination. The classification of defect in these pre-school children is in line with that prescribed by the Ministry of Education for school children. No. differentiation is made between major and minor defects, but no defect is recorded unless it is considered necessary to advise treatment or to keep the child under observation. 47 Defect No. of children in which found Teeth 511 Skin 99 Eyes (a) Vision 7 (b) Squint 103 (c) Other 22 Ears (a) Hearing 8 (b) Otitis media (R 5 (L 3 (c) Other 1 Nose or Throat 77 Speech 73 Cervical Glands 18 Heart and circulation 35 Lungs 29 Development (a) Hernia 17 (b} Other 21 Orthopaedic (a) Posture 74 (b) Feet 182 (c) Other 61 Nervous System (a) Epilepsy 7 (b) Other 8 Psychological (a) Mental Development 21 (b) Stability (Behaviour Difficulties 176 Other Defects 24 Fifty-one per cent of the children were found to be in satisfactory health and free from any defect, and in addition there were 15% in whom there was no defect except for carious teeth. Although there are no noteworthy changes from defects found in 1955, it is unfortunate that there is no decrease in the amount of dental decay. Health visitors and doctors continue to try to bring home to parents how an unbalanced diet containing too much starch can have a bad effect on the teeth. The habit of eating sticky sweets is particularly harmful unless followed by cleaning of the teeth at least by rinsing the mouth with water. The shortage of dentists in the Council's Service makes the task of dental health education more difficult. Regular inspection and, when necessary, dental treatment of preschool children, together with chairside individual advice by the dentist would, no doubt, be more effective. Jelly Tests for Tuberculosis. At Forest Street Clinic the "pilot scheme" for offering Jelly tests for all children attending for "birthday examination" has continued throughout the year. Out of 1,012 examined 823 were tested of which 822 were negative. This shows that of the children examined in this age group there was only one who had been infected with tuberculosis. Further investigation of this child confirmed a mild degree of positivity, but her x-ray was within normal limits, thus indicating that although infection had been acquired, resistance was good and no treatment was required. 48 So far those tests have shown that very few of the children examined have come in contact with the infection in sufficient degree to acquire either immunity to tuberculosis, or the disease, and they have not helped in tracing any unknown source of infection amongst adults. In November of 1956 the scheme was extended to cover children invited to attend at the tedders Clinics throughout the Borough, and it will be interesting to see whether the result are Similar. Attendances at all the Child Welfare Sessions (including the Toddlers' Clinics') are set out below for the period 1952-1956. The percentage of children in both age groups who have attended shows very little variation from the previous year. Children under 1 Year Children 1-5 Years 1952 1953 1954 1955 1956 1952 1953 1954 1955 1956 Number of individual children *2,042 2,336 2,309 2,166 2,179 5,596 5,526 5,169 5,012 4,569 (74%) (821%) (85%) (81%) (85%) (44%) (46%) (47%) (45%) (43%) Number of attendances +26,024 25,592 25,969 23,774 23,367 14,038 13,596 11,384 10,998 11,047 (12.8) (10.0) (11.2) (10.9) (10.7) (2.5) (2.5) (2.2) (2.2) (2.4) Notes:- * figures shown in brackets indicate the approximate percentage of available children within the age groups who attended the Clinics. + Firures shown in brackets indicate the average number of attendances made by each child. Consultant Clinics The number of pro-school children referred to the specialist clinics available on local Authority premises (through the School Health Service) during 1956 were as follows:- Ophthalmic 109 Ear, Nose and Throat 12 Paediatric 41 Child Guidance 1 Speech Therapy 8 With certain agreed exceptions, there is consultation between the clinic medical officer and the family doctor, before a child is referred to a specialist clinic or hospital. A copy of the report is sent to the family doctor. 49 Survey of Vitamin Intake in Infancy. Attention has recently been drawn to the increasingly large amounts of Vitamin D being given to infants, now that nearly all dried milks (including national dried milk) and specially prepared infant cereals contain substantial amounts of added Vitamin D. These large amounts are unnecessary and occasionally, perhaps in particularly susceptible babies, they may be harmful. Interest in this matter having been stimulated by surveys made in other areas, particularly in Belfast, we decided to collect information about the amount of Vitamin D being given to three month old babies in West Ham. This age group was chosen because, at this age, few babies are receiving any foods, apart from milk and vitamin supplements. West Ham Survey. The babies included in the survey were those born in January and February, 1956, and although babies who were not found in their homes were not followed up, the numbers indicate that only a few were missed. The health visitors who normally visit all three month old babies recorded the kind and the amount of milk and of all supplements likely to contain Vitamin D or Vitamin C which the baby was having. The amount of these vitamins taken daily by each baby was then calculate: in the office. In addition to giving us the desired Information regarding vitamin intake, the survey gave interesting information about the kind of milk which the babies were having. Results Feeding Out of 299 babies for whom the information was recorded - At the age of 3 months 82 (27%) were completely breast fed, 14 (5%) were partly breast fed and 203 (68%) were artificially fed. Of the 203 artificially fed 95% were fed on dried milk (mostly national dried milk). Vitamin D. Out of 299 babies- 23% received less than 600 I.U. Vitamin "D" daily. 25% received 600-1,000 I.U. Vitamin "D" daily. 51% received 1,000-2,000 I.U. Vitamin "D" daily. 1% received over 2,000 I.U. Vitamin "D" daily. Except for those who were breast fed, all the babies were probably receiving unnecessary large amounts of Vitamin D, and some were receiving very large amounts. The lesson to be learnt from this is that although it is essential on account of the climatic conditions of this country and our smoky atmosphere, to make sure that all babies are receiving sufficient Vitamin D to prevent rickets, care is needed to ensure that they are not receiving amounts which are unnecessary, and may be undesirable. This applies particularly to babies fed on dried milk. The health visiting service is now in a better position to appreciate the situation and to advise mothers on the amount of Vitamin D supplement which should be given to each individual baby in the light of the milk and other substances which the baby may be taking. 50 Vitamin C. Another interesting fact brought to light by the survey is that these young babies were nearly all receiving an insufficient amount of Vitamin C. This should be remedied because, although there are few cases of frank scurvy seen in this country, there are many vague conditions which may be caused or aggravated by insufficient Vitamin C. A baby fed on dried milk receives no Vitamin C in his feeds. After the first 2 to 3 weeks it is very important to give adequate amounts of orange Juice (suitably diluted) rose hip syrup, blackcurrant syrup or other suitable preparation, or ascorbic acid in tablet form. The help and co-operation given by health visitors and medical officers in this Survey is greatly appreciated and has enabled the department to obtain very valuable information on which future advice can be based. Audiology Unit. The clinic, started in May 1955, has continued under the direction of Mr,C.J.Scott, consultant Ear, Nose and Throat surgeon. The Team, whose other members are 2 health visitors with special training, the audiometrician, the Head Teacher of the School for the Deaf and the Senior Assistant Medical Officer, Maternity & Child Welfare, has held 8 sessions at Maybury Road Welfare Centre. Close liaison has been maintained with the Educational Psychologist, who has been asked to test children who appeared to be backward and who has in turn, referred to the Team pre-school children whose behaviour during testing has suggested some impairment of hearing Eight sessions were held during the year and 25 children were seen, 4 of whom were examined on three occasions, and 2 were examined on two occasions. Of these 25 children 4 were deaf 1 partially deaf required speech training 2 were placed on the waiting list for the removal of tonsils and adenoids 4 showed general backwardness (rather than impairment of hearing) 5 were referred for further observation 3 were found to be normal 2 were found to be "behaviour problems". The team are gradually improving their skills in the difficult technique of examining these very young children. Home visits by the health visitors, and more prolonged observation of the child in the nursery class of the School for the Deaf (for a few hours, or a whole day) have been very helpful in enabling the Team to reach a conclusion about the child. In many cases this conclusion can only be tentative, the child's development and response to training must be kept under further prolonged observation. So far, most of the children referred to the uinit have been "Toddlers". It is hoped that younger children will be referred when the work of the unit becomes known and professional colleagues become more aware of the possibility of the diognosis of deafness in infancy. It is at this age, when the normal baby is learning to listen to imitate, and to speak, that the result of guidance and training are more far reaching. 51 Physiotherapy. The following table shows the number of pre-school children who have attended the Physiotherapy Clinics held at Grange Road and Forest Street Child Welfare Centres. These Centres, although held on Maternity and Child Welfare premises, are administered through the School Health Service, and treatment is offered to school children as well as to pre-school children. Sunlight Massage Exercises No. of individual children who attended 148 12 52 No. of attendances made by above children 2311 70 770 Handicapped Children. As in previous years health visitors and medical officers have continued to report to.the Senior Assistant Medical Officer, those pre-school children, however young, whose development did not seem to be proceeding along normal lines. Every effort has been made, in co-operation with the general practitioner, and consultant when appropriate, to arrange for special investigations and treatment and to give helpful guidance to the parents. "Ascertainment" has only been carried out before the age of 5 years when it has seemed useful in securing treatment or admission to school or institution. At the end of the year there were 80 children who were being kept under careful observation. Of these 10 had been ascertained. Ascertained Not Ascertained Total Age 4-5 years 5 22 27 "3-4" 3 20 23 "2-3" 2 18 20 "1-2" - 5 5 " Under 1 year - 5 5 10 70 80 The 10 children "ascertained" were placed in the following categories:Deaf 3 Physically Handicapped 2 (Cerebral Palsy) Mentally Defective 4 Blind 1 10 The 70 children not yet ascertained would appear to come within the following categories Mentally Retarded 37 Physically Handicapped l8-14 Congenital Defect 3 Cerebral Palsy 1 Poliomyelitis Epileptic 8 Defective Speech 3 Deaf 2 Impaired Vision 2 70 52 During 1956 five West Ham children under 5 years attended the School for the Deaf; they were all admitted prior to 1956 and at the end of the year two had reached their fifth birthday. There were 3 children under 5 years of age attending the Spastic Unit. There were no children of pre-school age attending the Occupation Centre, nor on December 31st were there any in institutions for mental defectives, although one or two 4 year olds had been admitted during the year. At our request and with the agreement of the Director of the Child Guidance Clinic the Educational Psychologist tested a total of thirteen children under 5 years, four of whom she had examined in previous years. The ages of children seen by the Psychologist are as follows Age First Exam ReExam 4-5 4 2 3-4 3 2 2-3 2 - 1-2 - - Total 9 4 Day Nurseries and Child Minders. Two Day Nurseries remained open during the whole of 1956; the following table shows the average attendances Nursery No. of Approved Places Average Daily Attendance Under 2 years Over 2 years Total Litchfield Avenue 51 14 24 38 Plaistow Road 54 13 23 36 The numbers in attendance have fluctuated considerably, some children being admitted on a temporary basis to ease difficult family situations. With children in this age group there are bound to be absences caused by illness of mother or child, holidays, and other family reasons, such as relatives being temporarily available to care for the child. 53 There were 134 admissions to Day Nurseries during 1956. All children accepted for admission some within the priorities defined by the Council as follows:- First Priority: Parents separated 15 children Mother unmarried 15 " Mother widowed 3 " Father in prison 1 child Father in H.M.Forces 2 children Children deserted by father 2 " Children deserted by mother 4 " Parents divorced 3 " Health of child 2 " " " mother 2 " Children from "Problem Families" 2 " TOTAL: 51 Second Priority: (Financial grounds, etc.) 70 Temporary admissions 13 TOTAL: 134 The following is an analysis of the temporary admissions and the average number of days the children spent in the Nurseries. Mother's confinement in Hospital 2 admissions - average stay 25 days Mother in Hospital for treatment 1 " “ " 28 " Mother in Mental Hospital 3 " " “ 35 " Mother ill 4 " " " 74 " Child Minder going on convalescence 1 " " “ 20 " Mother "helping out" at husband's firm during holiday period 2 " " " 11 " On 31st December 1956, there were 103 children on the Day Nursery Registers. One of these was under 6 months of age, 9 were between 6 months and 1 year, 21 were between 1 and 2 years and 72 were between 2 and 5 years. The length of stay of these children in the Day Nurseries is as follows:- 4-5 years 1 child 3-4 years 1 child 2-3 years 5 children 1-2 years 22 children Under 1 year 76 children TOTAL: 105 This analysis of the reasons for admission shows that the nurseries are fulfilling a real social need in the community and helping to prevent the break up of families. Most of the parents Whose need is financial are not seeking to shed responsibility for the care of their young children, but are anxious to have the opportunity to save in order to buy a house or to furnish their new premises. 54 There are also a number of children, whose development is somewhat retarded, and whose limited background does not provide the necessary stimulation, who could benefit by care in a day nursery. Apart from 11 cases of whooping cough in Plaistow Nursery at the beginning of the year there has been no outbreak of infectious disease. One case of Sonne dysentery occurred in each nursery, but it is gratifying to report that the symptoms were detected promptly and there was no spread of the illness amongst the other children. There were also 12 cases of diarrhoea which occurred singly at Litchfield Day Nursery, but none were serious and all the bacteriological investigations were negative. There were a few cases of impetigo in each nursery, a rather unusual occurrence these days. The Cumberland Road Day Nursery, which is under the auspices of the Canning Town Women's Settlement, has provided places for 30 children throughout the year. It is visited regularly by one of the Council's health visitors, and by a medical offioer from time to time, There was only one child minder on the register, and she did not have any children in her care during the year. Welfare Foods. The distribution of Welfare Foods from the Child Welfare Centres, the Public Hall Canning Town, and the local W.V.S. Headquarters has continued throughout the year. Convalescence. The following are the number of mothers and children sent for recuperative holidays during 1956:- Unaccompanied children under 5 years 23 Mothers with Children 61 54 This shows a further decrease in the number of unaccompanied pre-school children sent away and is in accordance with our policy of not encouraging separation from their mother except for urgent reasons. A follow-up is generally carried out by the health visitor when mothers and children return from convalescence, and mothers have usually stated that they have felt much better and have enjoyed their stay. Enquiry has revealed that good progress has been maintained following convalescence and it therefore appears that a much needed service is being provided. Twenty-five of the mothers, some with 2 or more children, have been to "Wlnterton House" in Buckinghamshire. The usual stay is for 2 weeks but sometimes, if mother and children are deriving obvious benefit, but are not fully recovered, the period is extended on the recommendation of the medical officer of the Home. We are muoh indebted to the officers of Buckinghamshire County Council who administer the Home and to the staff of Winterton House, for the good and kindly care given to the mothers and children, the very efficient arrangements for their reception, and their helpful co-operation at all times. 55 Once again the administrative arrangements for convalescence have been undertaken by the West Ham Branch of the Invalid Children's Aid Association, and are in the capable hands of their Secretary, Miss Weekes. Liaison with Children's Officer. There are frequent consultations and informal discussions between the staff of the Health & Children's Departments, relating mainly to children in care or "neglected" or to "problem families". More formal conferences have been convened from time to time by the Children's Officer and these have proved very helpful in co-ordinating the efforts of the various Council departments and voluntary organisations. They have been very well attended, and under the Chairmanship of the Medical Officer of Health, valuable work has been done in giving continuing support to families which have shown such social inadequacy that they are unlikely to continue to survive as a family, without such support. The Council's medical officers visit the 9 "family group" homes and the 2 residential nurseries to examine the children at regular intervals. They also undertake the regular medical examination of children boarded out in West Ham, and are available for consultation as required. Vital Statistics. The following are the statistics for 1956 compared with the provisional rates for England and Wales which have been published by the Registrar General:- For For West Ham England and Wales Stillbirth rate per 1,000 total births 21.9 23.0 Infant Mortality rate per 1,000 live births 24.4 24.0 Neonatal Death rate per 1,000 live births 15.4 16.9 Maternal Mortality rate per 1,000 live births and stillbirths 1.14 O.56 The stillbirth rate, although higher than last year's, is below that for England and Wales. The infant mortality rate which is higher than last years is now about the same as the national figure, while the neonatal mortality rate is exactly the same as last years and still below the national rate. The increase has been in the deaths of children between one month and one year, of which there were 25 in 1956 as compared with 16 in 1955. Four of these deaths were caused by acute suppurative broncho-pneumonia - a rapidly fatal condition whose cause is still not fully understood, while 7 of the babies had congenital malformations. A full analysis of the causes of infant deaths is given overleaf, and the total infant deaths and stillbirths combined are shown in the diagram, the number being 119 (63 deaths and 56 stillbirths), an increase of 12 from the previous year in which there were 56 deaths and 51 stillbirths. The perinatal mortality rate (calculated from the number of stillbirths plus the number of deaths in the first week of life) is a figure which is increasingly used as an Index of the loss of Infant life, due to factors acting in the ante-natal, natal and immediate post-natal periods. For West Ham this was 35.5 1956 as compared with 33.3 in 1955 and 40.1 in 1954. Of the 36 West Ham babies who died in the first week of life, 25 were premature. 56 Deaths under 1 year. The Classification of causes of deaths in infants under 1 year is as follows:- Pneumonia 10 Meningococcal Infection 1 Other diseases of respiratory system 1 Whooping Cough 1 Congenital Malformations 7 Other Defined & I11 Defined Diseases 40 Accidents 2 Other infections & Parasitio Diseases 1 63 Although the full details from which the Registrar General compiles his statistics are not accessible to the Health Department, it would appear from such information as Is available that the 40 infant deaths classified as "Other defined and I11 Defined Diseases" are made up as follows:- Prematurity 21 Prematurity & Respiratory Failure 1 Prematurity & Atelactasis 3 Atelactasis 2 Intracranial Haemorrhage 2 Meningitis 2 Cerebral Atrophy 1 Cerebral Haemorrhage Exomphalos 1 Meconium Ileus 1 Haemotoma of right suprarenal 1 Gastro Enteritis 1 Haemorrhagic disease of newborn 1 Amyotonia Congenita 1 Encephalitis 1 Erythroblastaemia 1 40 Of the 63 infant deaths, 38 occurred in infants who were under 4 weeks of age, and of these infants 25 were premature. Detailed information is available in respect of the 38 deaths of infants under 4 weeks of age, and is shown in the following table:- Age. Weight Place of Birth Under 12 hours 8 Over 5½ lbs. 12 Born in Hospital 38 12 - 24 hours 3 Premature 1 - 7 days 25 Under 2 lbs. 7 1-2 weeks 1 2 lbs. - 3 lbs. 9 3-4 weeks 1 3 lbs. - 4 lbs. 5 4 lbs. - 5½ lbs. 5 38 38 38 Thirty four died in the hospital In which they were born, and 4 were transferred to another hospital. 57 Deaths of children aged 1-5 years. There were 10 deaths as compared with 5 in 1955 Two were due to tuberculosis, 1 was due to a road accident, 1 to leukaemia, and 2 to respiratory infection. There were no deaths in this group from malignant disease. Maternal Deaths. The maternal mortality rate is high this year as there were, unfortunately, 3 maternal deaths. Two were due to septic abortion, and the third, which occurred in a hospital outside the borough, was due to pulmonary embolism following Caesarean section for obstructed labour. 58 59 SECTION 23: DOMICILIARY MIDWIFERY The West Ham Borough Council now provides directly the domiciliary midwifery service to the whole of the borough with the exception of the northern fringe. In this area some of the mothers book midwives from the Lady Rayleigh Training Home which is about ½ mile outside the borough, and is administered by the Essex County Council. At the 31st December there were 6 domiciliary midwives on the staff. Supervision of Midwives. The Senior Assistant Medical Officer for Maternity and Child Welfare has continued to act as medical supervisor of midwives. The Non-Medical Supervisor of Midwives, who is also the supervisor of home nurses, left towards the end of the year to take up similar duties in her home town after 2 years service in West Ham, and on the 31st December her successor had not yet been appointed. Maternity Outfits, each with an 8 ounce bottle of dettol, are supplied at the appropriate time through the domiciliary midwives to all expectant mothers who are to be confined at home. Administration of Analgesia by Midwives. All the domiciliary midwives employed are qualified to administer gas and air, and have been trained in the administration of Pethidine. The number of machines available for the administration of gas and air analgesia is sufficient for all home confinements, and for demonstration. to the mothers at the ante-natal clinics, so that they are familiar with its use before labour commences. By the end of the year 3 Trilene machines had been bought and were already in use by some of the midwives. It is hoped to extend this number so that eventually each midwife will have her own machine and will have been trained to use it. Out of 313 domiciliary confinements, gas and air was given to 111 mothers (approximately 35%) and Pethidine to 77 mothers (approximately 25%) and Trilene to 40 mothers (approximately 12$). Refresher Courses for Midwives. In Conformity with the rules of the Central Midwives Board, 1 midwife attended a refresher course during the year, and the supervisor attended a special course for supervisors of midwives. Relaxation Classes. During the year we were able to restart, at a number of clinics, the "relaxation and preparation for motherhood" classes on the lines previously organised at West Ham Lane Clinic (which had had to be suspended during the reorganisation of the midwifery service). Groups are formed as and when there are sufficient numbers of mothers, at the appropriate stage of pregnancy. Each group usually follows a course of 8 weekly sessions, at which the midwife undertakes the training in relaxation, breathing exercises, and posture. Health Visitors from the clinic generally Join the mothers for tea and give a short talk and lead the discussion which follows. Visual aids such as the birth atlas and film strips are used from time to time. 60 Training of Pupil Midwives. All the municipal midwives have co-operated in the district training of pupils who have already completed six months training at Plaistow Maternity Hospital, and continue to reside in a hostel attached to the hospital, their tutor being a member of the hospital staff. Co-ordination of Maternity Services. The consultations between the midwife and the doctor who provides the patient with maternity medical service have developed in a gratifying way, and a number of doctors now go to the municipal ante-natal clinics in order to examine their patients with the midwife. Ante-Natal Care and Toxaemia. In May, 1956, the local health authority received a copy of a letter sent by the Ministry of Health to the Chairmen of those Hospital Management Committees having a substantial number of maternity beds. This accompanied a memorandum embodying recommendations made by the standing Maternity and Midwifery Advisory Committee and endorsed by the Central Health Services Council. This memorandum emphasises the need for close co-operation between all those who undertake ante-natal care, particularly in relation to the prevention of toxaemia in pregnancy. As requested by the Ministry, the Chairman of the West Ham No. 9 Group Hospital Management Committee called a meeting of medical representatives of the hospital, general practitioners' and local health authorities (East and West Ham) to discuss this memorandum. Meetings were held on October 3rd and October 10th under the chairmanship of Dr.Coroyns, and were well attended. West Ham was represented by the Medical Officer of Health, the Senior Assistant Medical Officer for Maternity and Child Welfare and the Non-Medical Supervisor of Midwives. Prior to receiving the circular we had already had several meetings with representatives of the three maternity units in the borough and had disoussed a number of points which now appeared on the agenda. Nevertheless, useful recommendations for improving co-operation were formulated, and it was very helpful to be able to include our general practitioner colleagues in the discussions. Some of the recommendations can be implemented forthwith: others have been referred to the Local Obstetric Committee. Though the memorandum and the recommendations have served to emphasize the risk to mothers of toxaemia of pregnancy and the vital importance of early, continued and co-ordinated ante-natal care, they only underline knowledge which was already available. Moreover, no administrative action can be effective without the individual effort of each and every person connected in any way with the care of the expectant mother. behoves every such person to give of his best, by keeping abreast of knowledge and its applications to his own work. It is also essential that each should have a proper comprehension of what the other services have to offer, and should make good personal contact with his colleagues. 6l Maternity Services. Total live births notified as West Ham births during the year 1956 was 2.579 and of these 12% were born at home and 88$ born in hospital. Domiciliary births within the Borough 306 ) Domiciliary births outside the Borough 3 ) Hospital births within the Borough 2,100 ) 88% Hospital births outside the Borough 170 ) 2,579 Number of Live Births in Maternity Units in the Borough. Hospital West Ham Residents Live Births Forest Gate 937 1,854 Plaistow Maternity 805 1,057 Queen Mary's 358 696 TOTAL: 2,100 3,607 [Midwives attending at Domiciliary Confinements. Source Number {or equivalent number) of midwives on 31.12.56 Number of Live Births Municipal 6 283 Essex County Nurses Training Home 2 23 TOTAL: 8 306 All the domiciliary midwives undertake the training of pupils. the midwife acted as maternity nurse in 4 of the domiciliary confinements. Medical Aid was summoned in 124 cases. In 83 of these help was required for the mother only, in 40 for the baby only, and in the remaining 1 case help was summoned on account of both mother and baby. 62 SECTION 24: HEALTH VISITING. Staffing - The joint establishment of 40 health visitors and school nurses (apportioned as 22 to the Health Committee and 18 to the Education Committee) has never yet been filled. All trained health visitors undertake duties in the School Health Service, as well as in maternity and child welfare and more general public health work. There is still a small number of school nurses who are not trained health visitors and are too near retirement to take additional training. They work mainly in the School Health Service, but sometimes take clinic duties at the Maternity and Child Welfare oentres. At the and of the year the health visiting and school nursing staff was as follows:- (a) Superintendent Nursing Officer and Deputy Superintendent Nursing Officer (b) 26 health visitors employed on Joint Health Visiting/School ) Nursing duties ) 34 (c) 8 school nurses employed solely on School Nursing duties ) (d) 1 health visitor employed by the South West Ham Health Society )Not included (e) 3 health visitors (out of an establishment of 4) employed )in the estab- on Tuberculosis work )lishment of )40 health )visitors/school )nurses. Five student health visitors completed their training under the Council's scheme, and were appointed to vacancies on the establishment. They are under contract to give the Council two years' service. At the end of the year there were three students in training, but the department is finding it increasingly difficult to recruit suitable students. Three health visitors resigned during the year. They had been in the department for:- 1 over 7 years (resigned to take Queen's District Nurse Training, and then to Canada) 1 for 7 years (obtained an appointment in the Children's Department) 1 over 2 years - to Croydon as Health Visitor/School Nurse One School Nurse retired (14 years service in 2 periods) Out of our present 26 health visitors, 24 have been trained under the Council's scheme. 9 have been with us less than 2 years and are still under contract. 8 " " " " 2 years 3 " " " " " 3 years 4 " " " " " 4 years 1 has been with us 5 years 63 Home Visits First Visits Total Visits To expectant mothers 1,202 2,326 To children under 1 year 2,598 15,561 To children 1-2 years - 8,306 To children 2-5 years - 19,477 Special visits - 4,526 Refresher Courses. One tuberculosis health visitor attended a refresher course. One of the other health visitors should have attended, but was unfortunately unable to attend through illness. Extension of Health Visitors Duties. The diabetic and paediatric liaison schemes previously outlined have continued, and serve a very useful purpose. The work of the geriatric liaison health visitor increased to such an extent that another of the health visitors was chosen to share the duties. Each district health visitor now carries a considerable case load of old people whom she visits at varying intervals according to their ciroumstances. All the "specialist health visitors" carry out their functions on a part-time basis, in addition to the regular work on their own districts. The visiting of mental defectives under school leaving age is now undertaken by the district health visitors, who work closely with the senior mental health officer, and there have been interesting developments in the field of co-operation between the health visitor and the psychiatric sooial worker. Health Education. Health education activities have continued on the same lines as previously, and the personal interview still remains the most appreciated way of teaching. A considerable number of visual aids have now been collected in the department, and are used by the health visitors, both in the clinics, and in a number of talks given to various gatherings in the area. Increasing and very effective use is made of all the blackboards whioh have been provided at the centres. 64 HOME NURSING SERVICE. The staff of the Lady Rayleigh Training Home continue to provide the Home Nursing Service for the part of the Borough north of the District Railway Line (under agency arrangements with the Essex County Council). The remainder of the Borough is covered by the Council's own Home Nursing Service, operating from the Centre in Liverpool Road. Home Nursing Staff on 31st December, 1956. 1 State Registered Nurse ) Employed full time. 2 State Enrolled Assistant Nurses ) 9 State Registered Nurses ) Employed part-time 9 State Enrolled Assistant Nurses ) average 24 hours weekly. Summary of Work carried out by Home Nurses. Total Cases Total number of Average Number of Attended Visits Paid Visits per case 3,107 93,541 30.1 The cases treated by West Ham Home Nurses and the Lady Rayleigh Training Home are as follows:- Conditions Total Cases New Cases Total Visits West Ham Lady Rayleigh Total West Ham Lady Rayleigh Total West Ham Lady Rayleigh Total Medical 422 1,611 2,033 279 1,314 1,593 20,853 48,944 69,796 Surgical 92 164 256 81 130 211 2,555 5,656 8,211 Tuberculosis 57 38 95 52 30 82 2,649 1,837 4,486 Infectious Diseases 1 4 5 1 4 5 8 22 30 Maternity 14 6 20 14 6 20 103 50 153 Miscarriages 2 6 8 2 6 8 10 49 59 Other conditions 690 - 690 618 - 618 10,805 - 10,805 1,278 1,829 3,107 1,047 1,490 2,537 36,983 56,558 93,541 Grand Total: 3,107 2,537 93,541 There has been a slight decline in the number of patients attended, but the total number of visits has risen again because of the increase in the number of visits paid to each patient from 28.3 to 30.1. 65 Age groups of patients treated are as follows:- Total Cases New Cases Total Visits West Ham Essex Total West Ham Essex Total West Ham Essex Total Under 5 years 43 67 110 42 66 108 173 345 518 5-64 551 847 1,401 484 754 1,238 12,597 20,569 33,166 65 and over 681 915 1,596 521 670 1,191 24,213 35,644 59,857 Total 1,278 1,829 3,107 1,047 1,490 2,537 36,983 56,558 93,511 Grand Total: 3,107 2,537 93,5^1 Further progress has teen made in encouraging able-bodied patients to attend the Centre for routine treatments, but owing to the cost of transport this is largely limited to the Canning Town area. Loan Scheme. The scheme for the loan of nursing equipment has been increasingly used and has proved of great assistance in improving the care of sick persons nursed in their own homes. Future of the Service. There has been no improvement in the recruitment of trained staff for full-time employment. The part-time staff are the mainstay of the service and we have been fortunate in retaining many of the present staff for over 5 years. Most of these are married women and some of them (who have older children) are now able to work additional hours. This has been a considerable help to the service and enabled all requests for nursing care to be met. Any extension to cover a later evening service, although desirable, cannot be contemplated until an appreciable increase in full-time staff is achieved. This continued shortage of whole-time nursing staff is a serious national firoblem. The limited number of staff who qualify each year tend to remain in the hospital service. The very nature of the home nursing duties in districts such as West Ham, requires a special vocational attitude to the job and does not appeal to many newly qualified nurses. The answer to the problem may lie in the employment of some less qualified personnel who, though not having had previous nursing training, could be trained to carry out the simpler nursing procedures, such as blanket bathing patients who are not acutely ill and who do not need expert nursing care. Suitable training could be obtained by attendance at a basic course, supplemented by practical work under the guidance of experienced home nurses. Such trained staff would provide a means by which qualified nurses, who are in short supply, could be released from routine work to give more time to nursing the more seriously ill patients. The number of persons suitable for this work will also be limited, and the conditions of their employment will have to be made really attractive in order to compete with the claims of local industry. It is hoped that a laundry service for the incontinent sick and aged will materialise in the near future. The service will be of great help, not only to the old people themselves, but also to the home nurses who find it discouraging to have to nurse without an adequate supply of clean linen. 66 SECTION 26:- VACCINATION AND IMMUNISATION. There were no significant developments in this service during the year. SmallpoxVaccination. The following table shows the number of vaccinations carried out during the year. TABLE A. Number of Persons Vaccinated (or re-vaccinated). Age at date of vaccination Under 1 1 2 - 4 5-14 15 or over Total Number vaccinated (primary) 418 54 13 20 73 578 Number revaccinated - - 5 16 106 127 Of these vaccinations, 361 were performed by general practitioners and 344 by medical staff of the local authority. No complications from vaccination were reported during the year. Diphtheria Immunisation. The number of children immunised during the year by medical officers of the authority or reported as having been immunised by general practitioners in the area are given in the following table TABLE B. A. Children who completed a full course of immunisation. AGE at date of final injection Under 1 1-4 5-14 TOTAL 818 1,779 3,055 5,652 B. Children who received a secondary reinforcing injection. 41 3,804 19,206 23,051 67 The following table gives the estimated proportion of children in any age group who have received a course of immunisation since 1st January, 1942. Number of children who had completed a course of inmiunisation at any time between 1st January 1942 and 31st December 1956. TABLE C. Age at 31.12.56 i.e. born in Year Under 1 1956 1-4 1955-1952 5-9 1951-1947 10-14 1946-1942 Under 15 TOTAL Last complete course of injections (whether primary of booster) 30 7,573 11,190 11,951 30,744 A.1952-1946 B.1951 or earlier - - 219 280 499 C.Estimated mid-year child population 2,540 9,860 26,500 38,900 Immunity Index 100A/C 1.18% 76.91% 87.32% 79.03% Poliomyelitis Vaccination. The Ministry of Health Circular 2/56 gave details regarding the vaccination of children against poliomyelitis. Arrangements were immediately made for the registration of children in the 1947-1954 age group whose parents wished them to be vaccinated. By the closing data, 14th April, 1956, 6,500 registration had been made. Owing to the vaccine being in short supply authorities were to be issued vaccine in proportion to the number of registrations and to start with the Medical research Council selected the children to be vaccined first acoording to their month and year of birth. Instructions were also received regarding the reporting of notified cases of poliomyelitis, whether vaccinated or not, to the Statistical Research Unit of the London School of Hygiene and Tropical Medicine where the assessment of the protective effect of the vaccine was to be made. Vaccinations were commenced on the 12th May, and were suspended at the end of June. A few second doses were given in December making a total of 680 completed vaccinations during the year. A surprising feature was the number of cases that did not keep their appointments. Some were unable to on account of sickness, contact with infectious disease and holidays, and asked to have the vaccination deferred. Others, however, gave no reason and it can perhaps be assumed that they still had doubts about the safety of the vaccine. There were no untoward reactions or complications in any of the 680 children who received the poliomyelitis vaccine. 68 B.C.G.Vaccination. A high Incidence of tuberculosis is experienced by persons in the age group 15 to 25 years. The period after leaving school and entering employment carries a special risk of contracting the disease. A report of the Medical Research Council's Committee on Tuberculosis Vaccinations published early in 1956 indicated that vaccination with Bacille Calmette-Guerin (B.C.G.) an attenuated strain of the bacillus tuberculosis offered a substantial degree of protection when given to children shortly before they left school. In June of 1956 a scheme was introduced whereby all school leavers, that is school children of 13 years and over, are offered vaccination with B.C.G. Before vaccination is given a simple skin test is performed, as some children will already have been exposed to the disease and have subsequently developed an immunity. In these instances the skin test is positive and arrangements are made for these. children to have a chest x-ray to ensure that the previous exposure to tuberculosis has not resulted in active disease. Prom June 1956 until the end of the year fifteen schools were visited for this purpose with the following results. Number of children skin tested 1,808 " " " negative 1,296 " " " positive 512 Number of Children vacoinated 1,128 " " late reactors i{-3 69 SECTION 27: AMBULANCE SERVICE. The organisation of the service remained unchanged during the year with responsibility divided as follows:- Medical Officer of Health - Organisation and administration. Borough Engineer - Provision, maintenance and manning of vehicles. Chief Officer, Fire Brigade - Operational control of ambulances. The Acting Ambulance Officer and his assistant, who are on the staff of the Health Department, are responsible to the Medical Officer of Health for the day to day administration of the service, advance bookings for ambulances and ambulance cars, and act as liaison officers with the other departments concerned. The ambulance control is manned by two Assistant Controllers, who work on overlapping shifts covering the period from 8 a.m. to "J p.m. on weekdays, the remainder of the twenty-four hours, Sundays, and bank holidays being covered by Fire Brigade personnel. Operational vehicles are deployed as follows:Ambulances: Stratford Fire Station - 1 Plaistow Fire Station - 4- Silvertown Fire Station - 1 Transport Depot - 4 and 1 reserve vehicle. Ambulance Cars: Transport Depot - 11 The latter are provided from the Council's passenger car fleet, and include one 8-seater sitting case vehicle. Except in cases of emergency, or accident, transport is provided only if requested by a doctor or hospital. The service also provides transport for the "gas and air" analgesia sets used in connection with the Domiciliary Midwifery service; premature baby equipment is also available and can be conveyed to a case requiring it at a few minutes1 notice. Arrangements are made for patients making long Journeys to travel by rail; apart from being more economical and convenient thah providing an ambulance for the whole Journey, this usually means that the patient has a more comfortable Journey, and one which is completed In a shorter time. The diagrams below show the work done by the service since 1949 (Its first full year of operation); the demand, in terms of the number of patients carried, is virtually unchanged, as forecast in last year's report, and the decrease in mileage per patient shows that efficiency is still increasing slightly. 70 71 SECTION 28: PREVENTION OP ILLNESS, CARE AND AFTER-CARE. TUBERCULOSIS. The statistics relating to notified cases of tuberculosis are given in an earlier section, page 11. There has again been a decrease in the number of cases notified during the year, and in 1956 there was the lowest number of deaths due to tuberculosis ever recorded in West Ham. Although these figures show a gratifying trend both in the incidence and death rate of this disease, there still remains scope for improvement and much work still to be done. The close co-operation between the Chest Clinic and the Health Department has continued. The Senior members of the Health Department and the Chest Physician meet for monthly conferences and olose working liaison has been maintained. (a) Work of the Tuberculosis Health Visitors. The health visitors have continued their regular home visiting of the tuberculosis patients and the appointment of a new member to the staff early in the year to fill the vacancy which existed for seven months in 1955 has resulted in an Increase of almost 1,000 visits to homes during the year. Home Visits Clinic Sessions 1955 1956 1955 1956 2,595 3,511 468 538 The four health visitors continue to deal with the many social and domestic problems which are involved in all cases of tuberculosis to a greater or lesser degree. This function as health adviser and sooial worker has done much to gain the confidence and co-operation of the patient both with the medical treatment and the after-care advised for his special needs. The health visitors have continued their work and liaison with the Tuberculosis Voluntary After-Care Committee and their knowledge of the families under their care has proved of great value to the Committee in making decisions on the cases presented to thera. This extension of the social work of the health visitor has proved a very important faotor in retaining the staff and the wider interest involved has supplied the much needed encouragement to the recruitment of trained staff into this special sphere of nursing. Social Work done by Tuberculosis Health Visitors. Number of cases dealt with 566 72 Preventive Measures. Child Convalescence 17 Adult Convalescence 23 Referred to Children's Officer - Referred to Housing Officer 26 Referred to Sanitary Inspector 12 Miscellaneous 30 After-care and Rehabilitation Referred to Disablement Resettlement Officer for work or training 44 Referred to Home Help Service 5 Referred to Occupational Therapist 17 Provision of Clothing and Bedding 68 Miscellaneous 46 Financial Aid National Assistance Board 67 Voluntary Funds (including After-care Committee) 211 The lending library is still popular but the average number of books borrowed has dropped to approximately 24 - 25 per week. I am indebted to the Chest Physician who has supplied much of the material contained in the following paragraphs. (b) Contact Tracing and B.C.G.Vaccination. As soon as a case is notified as suffering from pulmonary tuberculosis, appointments for contact examination are offered to all members of the family and to any other person known to be in close contact. In the case of adults, chest x-ray examinations are done and in the case of ohildren, x-ray examinations and tuberculin tests. Contacts both adult and children are kept under observation as long as it appears necessary. Children who are tuberculin negative are given B.C.G. vaccination, with the parents' consent. The following table shows the numbers of contacts given B.C.G. vaccination during the past five years:- Age 1952 1953 1954 1955 1956 0-1 46 59 70 51 49 1-2 12 5 12 12 17 2-3 6 9 13 11 10 3-4 7 17 13 9 7 4 - 5 5 10 16 4 9 Over 5 49 73 111 45 59 Total 125 173 235 132 151 73 In addition, 10 nurses employed at hospitals in the Borough were given B.C.G. vaccination. Special clinic sessions are held for contact cases and during the past year 581 contaots were examined as a result of 132 new cases, giving an average number of 4.4-0 contacts per notified case. The figures for this work in relation to those of previous years are:- Year New contaots New notified cases on Average number of contacts examined Clinic Register examined per notified case 1950 421 186 2.26 1951 643 196 3.28 1952 794 202 3.93 1953 916 226 4.05 1954 996 194 5.13 1955 605 157 3.85 1956 581 132 4.40 The scheme for the ascertainment of tuberculosis cases by tuberculin testing of toddlers was continued in the year under review and on active case was found. B.C.G.Scheme 1955. Epidemiological investigations of schools etc., in which tuberculosis cases had occurred were carried out in association with the Local Authority as required. The Medical Officer of Health is specially informed of any case of tuberculosis arising in a school child. Deaths from tuberoulosis of persons not previously known to the Clinic are followed up and steps taken to obtain the contaots, as far as practicable. (c) Rehabilitation and Employment of Known Cases of Tuberoulosis. Efforts are made to rehabilitate, as far as possible, cases of tuberoulosis who have undergone treatment. Cases suitable for employment are generally found work in consultation with the D.R.O. Cases who are permanently rendered incapable of employment are, if medically suitable, recommended for occupational therapy under the Local Health Authority services. The use is also made of the Ministry of Labour Training Schemes for suitable oases. The Council continued financial responsibility throughout the year for two male patients who were receiving rehabilitation and training at Papworth Hall and Elham Alamein Village Settlement. 74 Workshop Facilities for the Tuberculous. The informal exploratory discussions on this matter continued with a neighbouring authority. Arrangements for Convalescence. Cases referred by Chest Physicians were sent for convalescence before returning to work or following the completion of immediate treatment. Arrangements were made in respect of 14 adults and 17 children. (d) Ascertainment of Tuberculosis in Expectant Mothers. Further investigation and examination of expectant mothers found to be suffering from tuberculosis is carried out at the Clinic and speoial arrangements, where necessary, are made for their confinement. West Ham Tuberculosis Voluntary After-Care Committee. The Committee has continued to give much help in meeting the need for assistance required by families of patients in hospital, for extra nourishment, clothing and bedding for patients living at home. Assistance was given in 126 oases during 1956. Expenditure Included the following forms of assistance:- Fares to hospital. Clothing. Holiday grant. Extra Nourishment. Furniture and bedding. Removal expenses. Christmas gifts to patients. 75 OCCUPATIONAL THERAPY. The first Occupational Therapist resigned in January, 1956, and the newly appointed one did not commence duty until April, at which time there were 20 patients on the register. After visiting the hospitals in the area, meeting the Health Visitors, and some General Praotitioners from which patients would be referred, the number of patients on the register soon rose steadily, the majority of which fell into three main categories: (a) Tuberculous patients discharged from sanatoria (b) The chronic sick e.g. Multiple sclerosis, osteo and rheumatoid arthritis, hemiplegios (c) The mentally sick who had been discharged from hospital. The service has not been purely diversional, but has been designed whenever possible to aid the rehabilitation of the patient. Even when there is little hope of a return to full normal life, it has been found possible to limit the deterioration of patients suffering from erippling diseases. The present organisation of the service is well adapted to the requirements of domiciliary work, and is meeting a real need, but quite a number of patients would do better working in a group. The development of group therapy as opportunity offers will enable greater benefits to be brought to a larger number of patients. STATISTICS. Home Visits to Tuberculous patients Chronic sick M.Ds & mentally ill 139 197 66 402 During her short stay in the Borough, Miss Stevens the first Occupational Therapist was able to start a weekly class for Chest Clinic patients, which was held in the Health Visitors' office, Balaam Street, next door to the Clinic. This class has been maintained, with a total of attendances as shown by the monthly figures given below:- July 4 August 8 September 10 October 35 November 32 December 28 117 76 Convalescence. The arrangements for the provision of convalescence in cases where no active medical or nursing care is necessary were again fully used during the year, 14-6 adult persons being recommended for recuperative holidays, an Increase of 14 over the previous year. The sources of reference were:- General Practitioners 96 Hospitals 21 Chest Clinic 20 Other 6 Of the Initial recommendations, 23 were withdrawn, either by the patient or the referring agency, before consideration by the Council's medical officer; and of the 123 thus reviewed, 89 applications were approved, 27 were not approved, 5 referred to the Chief Welfare Officer, and 2 were referred for action under the Maternity & Child Welfare Scheme. Of the 89 approved, 14 were withdrawn for various reasons leaving 75 for whom convalescence was arranged. The procedure for assessment of the financial circumstances of each applicant In accordance with the Council's scale, continued as in previous years. The age and sex incidence of the cases placed in convalescent homes was:- #]Sex Under 25 25 - 45 - 65 - 75 - Total Male 1 - 12 7 1 21 Female 4 14 21 11 4 54 Total 5 14 33 18 5 75 In addition to the above, 17 children under the age of 15 years were sent to convalescent homes following recommendation by the Chest Physician as part of the preventive care and after care of tuberculosis patients. Details of the convalescence provided for mother and young children and for school children will be found on pages 55 - 56, and 138 - 139 respectively. Health Education. Talks, supplemented by film strips, sound films, posters, models, etc., were given on a variety of health subjects to parents and others at the various clinics and centres during the year. Request for lectures were also received from interested organisations in the Borough. Senior members of the department have taken part in the instruction of D.P.H. students, student health visitors, student sanitary inspectors and nursery students. Lectures were given to student nurses in the block training schemes run by the West Ham Group Hospital Management Committee and Whipps Cross Hospital. Their syllabus includes instruction in the social aspects of disease and requires both lectures and practical demonstrations of the Local Authority Services. It is a most valuable development in the training of the nursing profession and helps the students to understand the linking up of the medical care of the patient before and after his stay in hospital. 77 SECTION 29: DOMESTIC HELP. General Home Help. The number of cases on the register at the end of the year still continues to show an Increase over previous years. The number of applications during 1956, however, have decreased slightly. This is a reverse of the previous pattern which showed a steady increase in applications year by year. The age group mostly affected by this decrease is the under TO years in which applications have dropped by 3.7% as against last year's figure. The demand for home help from the over 70's continues to increase. Tuberculosis. The number of cases supplied with home help for the first time during 1956 remained the same as in the previous year. Of the 13 cases provided with home help for the first time 6 were in the under 50 group. Maternity. Applications for home help for maternity cases continued on the downward trend. Seventeen applications were made but only 10 received the service due to cancellation by the other seven. General Sickness, Aged and Infirm Cases. Number of applications received 372 Number withdrawn or refused 41 New cases accepted during 1956 331 Males 76 331 Females 255 ) Number of cases on books at end of 1955 767 Total number of oases receiving home help during 1956 1,098 Number of cases on books at end of 1956 771 Ages of Applicants to whom home help was supplied for the first time:- % Under 50 22 6.7 Between 50/59 20 6.0 Between 60/69 67 20.2 Between 70/79 167 50.5 Between 80/89 48 14.5 Between 90/99 7 2.1 331 100% Cases assessed to pay 10 Cases free 291 Average number of hours of service per case per week 3.3 78 Tuberculosis Cases. New applicants accepted during 1956 13 - Males 1, females 12 Number transferred from 1955 17 Total number of persons receiving home help during 1956 30 Number of cases on books at end of 1955 21 Age of Applicants to whom home help was supplied for the first time. Under 50 6 Between 50/59 4 Between 60/69 2 Between 70/79 1 Between 80/89 - Between 90/99 - Cases Assessed to Fay 4 Cases free 9 Maternity Cases. Number of applications received 17 Number withdrawn 7 Number received service 10 Staffing. Permanent full-time Home Helps employed at 31st December,1956 7 Part-time Home Helps employed at 31st December, 1956 100 Average hours worked per week per part-time Home Help (includes tuberculosis cases) 32.25 Total number of hours worked by Home Helps (approx.) 151,708 (On the basis of a 44- hour week, this is equivalent to 66.3 full-time Home Helps throughout the year, making no allowance for sickness, statutory holidays, annual leave and travelling time). Home Visits of Home Help Organiser and her Assistants. General Cases:- Visits to Applicants and Recipients 2,345 Visits to Home Helps 230 Tuberculosis Cases Visits to Applicants 276 Maternity Cases. Visits to Applicants 65 Total number of visits: 2,916 Office consultations - Applicants and Home Helps 4,500 approx, 79 SECTION 51 - MENTAL HEALTH SERVICE. The Mental Health Service continues to be administered by the Health Committee, the Medical Officer of Health being responsible for the organisation and control of the service. Staff. (a) Medical The Deputy Medical Officer of Health is responsible for the medical supervision and direction. This officer and the Chief Assistant School Medical Officer are approved by the local health authority for the medical examination of mental defectives. The Deputy Medical Officer of Health and three local general practitioners are also approved for the purpose of making recommendations under the Mental Treatment Act. (b) Lay Staffs. One Senior Mental Health Officer responsible for the lay administration of the service; two full-time Mental Health Officers carrying out duties under the Mental Deficiency and Lunacy and Mental Treatment Acts; ons relief Mental Health Officer who takes a regular turn on the duty rota for emergency calls omtside office hours; and one Psychiatric Social Worker. The establishment of the Occupation Centre consists of a Supervisor, three Assistant Supervisors and a Male Handicraft Instructor. Co-ordination with Regional Hospital Boards and Hospital Management Committees. The friendly relationship with the Regional Hospital Boards and Hospital Management Committees and especially with the staffs of Goodmayes Hospital and South Ockendon Hospital has been maintained. The Council's Mental Health Officers continued to supervise defectives on licence and also to visit and report on home circumstances, etc., for hospitals. The Psychiatric Social Workers employed by the Council and at mental hospitals work in close co-operation. Prevention, Care and After-Care in relation to Mental Health. The work of the Psychiatric Social Worker. The number of cases referred to the Psychiatric Social Worker in 1956 was 158. It is to be noted that the figures reveal a decrease in cases referred for after-care from mental hospitals, while there is a marked increase in cases referred for preventive work, especially by School Medical Officers. A more detailed survey of the preventive work by the Psychiatric Social Worker will be found under the heading of Pre-care Service. After-Care Cases. Though smaller in numbers, many of these cases have been or still are being seen regularly once weekly over a prolonged period ranging from one to two years. 80 Example. Case 1. Employment: Woman patient admitted to Goodmayes Hospital suffering from malnutrition, exhaustion and apathy. She was referred by a Health Department D.A.O. as In need of after-care by Psychiatric Social Worker, and help with employment. At the time of the referral, patient stayed in bed. in a darkened room until 2 p.m. She was quite incapable of applying to the N.A.B. or Labour Exchange, nor did she want to see her G.P. She was, however, able to keep her weekly appointments with P.S.W. who, in close co-operation with patient's G.P., the Area Officer of the N.A.B. and the D.R.O. of the Ministry of Labour, Was able to rehabilitate this patient. After 14 months of sustained work the patient,applied for a full-time Job in a factory found for her by the D.R.O. The patient has been working full-time satisfactorily for the last 9 months. Case 2. Housing: Mr.J. was referred to P.S.W. for after-care in 1955 by Belmont Hospital. An urgent request for rehousing was made by the psychiatrist. Mr.J., his wife and small child were living in one room at his mother-in-law's house in an atmosphere of severe friction. Although it was not possible to rehouse this couple until June 1957» P.S.W. together with the Health Visitor, who supervised the wife and child, were able to prevent this family from breaking down. Both these cases are being followed up at regular intervals. As can be seen from the above cases, a satisfactory result was obtained by close co-ordination of medical and social services. Pre-care Service. P.S.W. greatly welcomed the 17 referrals by the M. & C.W. section as well as the 35 cases referred by School Medical Officers. Example. Mother and child relationship: Mrs.G. and 5 year old Charles were referred to P.S.W. by a School Medical Officer. The child had shown signs of destructive behaviour and was unable to concentrate at school where the school teacher was not able to cope with him in a large group. Admission to a home for maladjusted children was under consideration. When mother and child came to see P.S.W. mother revealed that the child had reaoted badly to the marital dispute which had ended in the father's sudden departure. Mother is a full-time factory worker, and when she returned home she was quite unable to cope with the unruly child. Though the child sensed the conflict, mother had never actually talked to him about her dispute with father, nor mentioned father at all to the ohild. Mother came for 12 weekly interviews. Guided by P.S.W.mother was able to tell her child about her arguments with father, and also saw to it that the boy could meet him again. When the case was followed up after 5 months, mother reported that Charles is getting on well at school, and although he is still difficult, mother is able to stand up to him. Referrals from G.Ps. These showed a very welcome increase over the previous year, and it is hoped that an ever increasing number of G.Ps. will avail themselves of the services of the Psychiatric Social Worker. 8l The following details relate to the work of the Psychiatric Social Worker:- Referrals Pre-care 104 158 After-care 54 Sources of Referral Hospitals: Goodmayes Hospital 49 62 Whipps Cross Hospital 1 Queen Mary's Hospital 11 Claybury Hospital 1 Public Health Department: Medical Officer of Health 2 64 Deputy Medical Officer of Health 4 Duly Authorised Officers 4 Maternity & Child Welfare Section 17 School Medical Officers 35 Child Guidance Clinic 2 Disablement Resettlement Officer 1 32 Probation Officers 3 National Assistance Board 1 General Practitioners 11 Others 16 No. of Home Visits 274 No. of Office Interviews 464 Visits to Social Agencies, Hospitals, etc. 133 Intensive Casework 234 Short-Term Care of the Mentally Defective. Arrangements were made for 6 mental defectives to be accommodated for short periods under the terms of Ministry of Health Circular 5/52. Further details are given on page 85. Convalescence for Mental Illness. One patient, a woman of 32 years, received a period of recuperative holiday treatment under the Council's scheme. 82 Lunacy and Mental Treatment Acts. Work undertaken by the Mental Health Officers. There is no change In the arrangements for obtaining the services of the Mental Health Officers. A twenty-four hour rota system was in operation and calls for their • services after office hours continued to be made through Ambulance Control. During the year, the Mental Health Officers carried out the following work and visits in connection with these Acts:- 1. Calls received in connection with mental illness numbered 324 and were from:- (a) General Practitioners 183 (b) (1) Goodmayes Mental Hospital 48 (ii) General Hospitals 16 (c) Other Agencies (police, relatives, etc.) 77 |24 The total number of visits made to these cases was 581. Disposal of Cases. Two-hundred and fifty-three were admitted to hospital:- M. F. Total (a) As voluntary patients 60 101 161 (b) As temporary patients 5 13 18 (c) Under Urgency Orders 13 23 36 (d) Under Summary Reception Orders 5 5 10 (e) For observation 9 19 28 92 161 253 These were admitted to the following hospitals:- Goodmayes 219 St.Clement's (observation ward) 22 Others 12 The age incidence of these admissions was as follows Sex 0 - 15 - 25 - 35 - 4.5 - 55 - 65 - 75 & over TOTAL Male - 9 19 9 18 15 10 12 92 Female - 11 28 31 26 34 13 18 l6l TOTAL - 20 47 40 44 49 23 30 253 It will be noted that 30 of these admissions were of persons aged 75 years or over, with a total of 53 for persons aged 65 and over. 83 Of the 253 cases admitted to hospital through the Council's service, l6l (63$) were voluntary patients which is again an upward trend. Of those initially admitted under Urgency Orders and for observation, 87 (57%) subsequently consented to remain for voluntary treatment. In addition, 82 patients were admitted direct to hospital as voluntary patients either through the psychiatric clinics or by their private doctors. It can thus be seen that of the 335 patients admitted to mental hospitals from West Ham, 280 (83%) were voluntary patients. In 71 cases (22 males and 49 females) to which the Mental Health Officers were called no statutory action was taken as alternative means could be found of helping the patient in co-operation with the general practitioner either by reference to a Psychiatric Clinic, by sending the patient away for recuperative holiday, or by enlisting the aid of other persons who could help in one way or another. (c) Mental Deficiency Acts, 1913-1938. Ascertainment. Seventeen defectives (13 males and 4 females) were ascertained during the year. Of these, 14 (10 males and 4 females) were reported by the Local Education Authority (10 as being ineducable children and as needing supervision after leaving school); 3 cases (all males) were reported from other sources. Sixteen of these cases (13 males and 3 females) were placed under Statutory Supervision and the remaining case was admitted for institutional care. In addition to the ascertained defectives, 6 other cases came to the notice of the department. Two were plaoed under friendly supervision; 3 were not regarded as mentally defective and one was still under investigation at the end of the year. Supervision. At the end of the year 298 mental defectives (l6lmales and 137 females werw under statutory supervision, 3 under friendly supervision, and 8 on licenoe from institutions.' These cases were visited by the Mental Health Officers at approximately quarterly Intervals or more frequently if need be. In addition, informal contacts were maintained with other cases who it was felt might be in need of friendly help or guidance, i.e., border-line cases and those discharged from Order. The majority of the defectives under statutory supervision are in fairly regular employment and self-supporting. Those defectives considered capable of working but finding difficulty in obtaining employment of a suitable nature are referred to the Disablement Resettlement Officer and consultation takes place to decide the most suitable occupational placing. Visits in connection with the Mental Deficiency Acts during the year were as follows:- Cases under statutory supervision 1.191 Cases on licence from institutions 39 Reports for licence, holidays, etc., from the institutions 38 Reports for Statutory Visitors 85 Other visits 260 1,613 84 Guardianship. There were three defectives under guardianship at the end of the year. They were all females aged 62, 49 and 21 years respectively and have been with their present guardians for 21, 19 and 3i years. All are with guardians outside West Ham and were supervised by the local health authority of the area in which they reside. Cases under guardianship are visited at approximately six-monthly intervals by a member of the Health Committee and by one of the Council's medical officers. Temporary Accommodation for Defectives. During the year arrangements were made for 6 defectives to receive temporary care. Four were females aged 68, 41, 38 and 37 years and two were males aged 12 and 6 years. Five were accommodated at South Ockendon Institution by the kind permission of the Physician Superintendent and one by arrangement with the Guardianship Society, Brighton. Institutional Accommodation. Twelve defectives were admitted to South Ockendon Institution. The age and sex incidence was:- Male Female Children 0 - 5 Children 5 - 15 3 2 Adults 5 2 At the end of the year, there were 5 defectives in the area awaiting institutional accommodation. Three of these, adult males and former poor law patients, are in Forest Gate Hospital not under Order and are on the waiting list for admission to South Ockendon Institution. Home Training. No special arrangements existed for the home training of defectives^ Occupation Centre. There were 8 new admissions during 1956. At the beginning of the year there were 58 children on the register and at the end of the year in December 1956 there were 64 children on the register. Discharges were as follows 1 child left the district 1 child was admitted to South Ockendon Hospital. The annual outing of the children took place in May and they visited Lake Meadows, Billericay. It was a successful and a happy day for the children. In June the Handicraft Instructor be^m the praotical part of the N.A.M.H. Diploma Course from which he returned in October. In July there was an Open Afternoon for the younger groups In which there was a sale of children's handiwork. It was attended by about 50 visitors consisting of parents, officials and friends. In September one of the Assistant Supervisors began a year's Course for Teachers of the Mentally Handicapped held by the N.A.M.H. This was the first of the Occupation Centre staff to Join this Course. In November, an Open Day for the whole Centre was arranged and about 100 people attended. They were given an opportunity of seeing the children at work and the variety of activities and occupations which are included in their curriculum. At Christmas, the Children's Party was visited by the Mayor and Mayoress of West Ham, and Santa Claus paid his usual visit and delighted the children who thoroughly enjoyed the festivities. 85 SUMMARY The following are the statistical returns relating to mental defectives. 1. Particulars of Mental Defectives on Register as at 31st December, 195&. Under age l6 Aged 16 and over Total M. F. M. P. (a) Cases ascertained to be defective found "subject to be dealt with" (i) Under Statutory Supervision (excluding patients on licence) 41 19 120 118 298 (ii) Under Guardianship - - - 3 3 (iii) In places of safety - - - - - (iv) In hospital (including cases on licence therefrom) 28 11 1995 185 419 Total: 69 30 315 306 720 (b) Cases not ascertained to be defective found "subject to be dealt with" Under Voluntary Supervision 2 1 3 Grand Total: 69 30 317 307 723 (c) Number of oases in above receiving training In Occupation Centre 30 17 8 5 60 * Includes 3 oases in Forest Gate Hospital not under Order awaiting admission to South Ockendon Hospital. 86 2. Particulars of cases reported during 1956. Under age 16 Aged 16 and over Total M. F. M. F. (a) Cases at 31st December ascertained to be defectives "subject to be dealt with". Action taken on reports by:- (i) Local Education Authorities on children (1) While at school or liable to attend school 8 2 _ _ 10 (2) On leaving special schools - - 2 2 (3) On leaving ordinary schools - - - - (ii) Police or by Courts - - - - - (iii) Other sources 2 - 1 - 3 (b) Cases reported but not regarded at 31st December, 956, as defectives "subject to be dealt with". 2 - 2 (c) Cases reported but not confirmed as defectives by 31st December _ _ 1 2 3 Total number reported: 10 2 6 4 22 87 \ General Health and Welfare Services. National Assistance Act, 1948. National Assistance (Amendment) Act, 1951. Removal to Suitable Promises of Persons In Need of Care. A number of cases were reported to the Department with a view to possible action under these Acts during the year. Special visits were made and in four cases it was necessary to take urgent action. In the remaining cases the Department was successful in either persuading the patient to enter an institution voluntarily or in providing services such a Home Nursing, Domestic Help, etc. Details of the four cases dealt with are as follows Case 1 and 2. Two elderly sisters aged 80 and 78 years were reported by an officer of the National Assistance Board. When visited, they were found to be occupying a small upper back room. The other occupants of the house had helped them until it became impossible for them to do so in view of the younger sister's attitude towards them. They were found to be in filthy condition as regards their person. The room was bug-infested, extremely filthy, and the floor was covered with excreta and debris; the bed and bedding were badly soiled. The elder sister was crippled and had apparently not been out of the room for about 10 years. The younger sister was ill In bed. Neither sister was on a doctor's list and when hospital treatment was suggested this was vigorously refused by the younger woman who appeared to dominate her sister. An Order was obtained under the National Assistance (Amendment) Act and the patients were removed to Langthorne Hospital. The younger woman unfortunately died about three weeks after admission but her sister settled down quite well in the hospital. Case No. 3. Male, aged 83 years. This case had been under the surveillance of the Department for some time. With the aid of domestic help, Meals on Wheels, he was able to manage fairly well. He became ill and was persuaded to enter hospital voluntarily but soon afterwards he took his discharge. After a time his condition again deteriorated and he was re-admitted to hospital following intensive persuasion by his doctor. Again he was unwilling to stay and he took his own discharge. After this his condition deteriorated rapidly. He became dirty, refused to have any help and it became necessary to obtain an Order for his removal to Part III accommodation under the National Assistance (Amendment) Act, 1951. Although this man settled down fairly well it was necessary to obtain an extension of the Order from time to time. He unfortunately died about six months after admission. 88 Case No. Female. Aged 84 years. This case was brought to the notice of the Department by the General Practitioner. She had fallen out of a chair about a week previously and fractured her ribs but had taken her own discharge from hospital. When visited, she was lying in bed without any lighting facilities In the house. There was little food in the larder and the bedding and walls showed some signs of bug infestation. She would not agree to go to hospital. A further visit was made the following day and her doctor felt he had been successful in persuading her to enter hospital but when the ambulance called for her she refused to go. Arrangements were made for home nursing and for domestic help but a few days later the Home Nurse reported that the patient had two large bedsores, she was lying in a saturated and soiled bed. A further visit was made, the woman was unable to raise herself or turn over in bed and evidently needed urgent medical and nursing care in hospital. She would not, however, agree to go away so an Order was obtained under the National Assistance (Amendment) Act sending her to Langthorne Hospital. Unfortunately, this patient died about 10 days after admission. 89 Epilesy. A. Children. There is no change in the arrangements whereby all children between the ages of 2 years and 16 years found to be suffering from epilepsy are referred to the School Health Service for examination and any necessary action. If special educational treatment is needed and this cannot be met in the ordinary day school arrangements are made for the child's admission to either a special day or residential school. The number of children known to be suffering from epilepsy and their placing is as follows 1. In attendance at ordinary schools 53 2. In attendance at day special schools 1 3. In attendance at residential special schools 4 Total: 58 B. Adults. As there is no complete registration of persons suffering from epilepsy it is not possible to give a true picture of this defect. It is usually the more severe cases which come to notice and if such cases are in need of residential accommodation this is arranged by the Welfare Department under Part III of the National Assistance Act, 19^8. The number of West Ham cases of epilepsy in residential care at the end of the year was 12, these cases being accommodated as follows:- Forest House 3 Chalfont Epileptic Colony Prested Hall 1 Wessex House 4 In some further cases known to this department the epilepsy Is associated with a degree of mental deficiency. If institutional care is not required such cases may be placed under supervision in accordance with the provisions of the Mental Deficiency Acts. 90 SCHOOL HEALTH SERVICE SCHOOL POPULATION There was a very small decrease In the school population during the year. On the 31st December, 1956, there were 29,453 children on the school rolls, as compared with 29,487 on the corresponding day of 1955. The variation in the school population during the past four years has been very slight. MEDICAL INSPECTION The medical inspection of school children was carried out In accordance with the provisions of the School Health Service and Handicapped Pupils Regulations, 1953, in which a minimum of three inspections is prescribed during the period of school life. In West Ham the practice for many years has been to carry out as a routine the three general (or "periodic") medical inspections; Infant School entrants were examined at five years of age within their first year at school, junior pupils at 10 years of age in their last year at junior school, and senior pupils at 14 years of age during their last year at secondary modern school. At the Grammar and Technical schools, the 14 year old pupils are examined and thereafter at intervals of two years: all school leavers are also examined. In addition, special inspections or relnspectlons are undertaken as required. With the approval of the Minister a local education authority can arrange for less than three periodic examinations. The purpose of limiting periodic inspection to entrants and leavers is to enable the medical officers to visit their schools more frequently, so that they can give more time to Individual children who appear not bo be thriving or are not making satisfactory progress in school work. Consideration is being given to this method of examination as it appears to be a worthwhile experiment likely to Increase the efficiency of the school health service. There was a decrease of 479 In the number of periodic inspections and an increase of 672 in the number of special inspections and relnspectlons so, on balance, the amount of work carried out was much the same as in the previous year. The fall In the number of entrants examined (712) was due in part to a reduced intake of new entrants. The fall in the number of juniors examined (752) was due to a decrease In the birth rate in 1946, while the increase in the number of seniors examined (676) was due to an Increase in the birth rate in 1942. There was an increase of 309 in additional periodic Inspections. For the Ministry of Education returns children are regarded as falling into one of the three prescribed age groups (Entrant, Second Age Group or Third Age Group) only if inspected at the normal time at a periodic inspection. If they miss the usual periodic inspection and are inspected later, they are classed as "Additional Periodic Inspections". Inspections at grammar and technical schools after the normal school leaving age are classed as "Additional Periodic Inspections". The annual inspections at the day special schools and the first inspections of nursery school children in any calendar year, other than in their first year, are also classed as "Additional Periodic Inspection". Tables setting out the work done under the heading of medical inspection and treatment will be found in Appendix IV on pages 146-150. 91 Physical Condition. The medical officer's survey at the periodic medical inspections has Included an estimate of the child's general condition. This was classified into three grades; "Good", "Fair" and "Poor". The percentages in these three grades In 1955 were:- Good Fair Poor 41.07 57.70 1.23 A child placed in the "Good category had to be really good. He was a child well developed, with plenty of vitality and vigour and showing a keen Interest in life. A "Fair" child was a normal average or satisfactory child. A child in the "Poor" category was one who appeared tired, listless, undernourished, dull and perhaps with poor posture - he was under suspicion at once and he was fully investigated. The following table shows a comparison of the findings for the past ten years:- Year Excellent Normal Sub-normal and Bad 1946 23.76 61.97 14.27 Good Fair Poor 1947 79.43 20.19 0.38 1948 35.67 54.46 7.87 1949 35.06 56.16 8.78 1950 38.07 55.44 6.49 1951 39.03 53.44 7.53 1952 43.94 47.71 3.35 1953 44.69 53.97 1.34 1954 42.90 55.80 1.30 1955 41.07 57.70 1.23 This period covered the change which took place in 1947 from the Ministry's previous four point classification. For a period the figures showed instability, due largely to uncertainty of interpretation of the new categories. There are many factors which can influence this essentially subjective assessment, so that there still remained some doubt how far even the more recent figures could be regarded as giving a valid comparison. On the 1st January, 1956, a new system of classification was introduced and the medical officer now assesses the physical condition of the child rather than the general condition as in previous years. The results cannot, therefore, be compared with the assessments of previous years. There are now only two categories - "Satisfactory" and "Unsatisfactory". The reason for having two categories only is a practical one - every child whose physical condition is considered unsatisfactory should be thoroughly Investigated, Including his home conditions, so that he can be made as fit as possible. The figures for 1956 are as follows:- Satisfactory 99.87 per cent Unsatisfactory 0.13 per cent 92 Revised School Medical Record Card - Form 10M These new forms were brought Into use at the beginning of the year. Notes of guidance on the revised school medical record card approved by the Minister for the purposes of Regulation 10(3) of the School Health Services and Handicapped Pupils Regulations, 1953, were sent to local authorities in time for the commencement of work at the beginning of 1956. When a child is examined for the first time the new form is used; in the case of existing cards appropriate slips have been inserted in than. When stocks of the earlier approved forms are exhausted then the new cards will be in general use. The chief object of the revised school medical record card is to furnish a continuous record of events of medical importance In the child's life from the date of entrance to school until the time of leaving, and to provide some indication of the state of health of schoolchildren generally. It is pointed out by the Ministry that there should be sufficient uniformity in methods of recording to make the main record valuable when the child moves from one district to another. The main record card is kept in the central office of the school health service. It is a confidential document. Welfare of Schoolchildren. The School Health Service is the oldest statutory personal health service in the country - a fact perhaps not too well known - and it owed its formation largely to the report of the Inter-Departmental Committee on Physical Deterioration in 1904. This Committee was set up as a result of national apprehension at the physical state of the recruits during the Boer war and it identified the appalling defects in conditions bearing on the physical and moral welfare of children and young persons and decided that these were the most important factors in the alleged physical deterioration of the nation, and that long-term policy of child welfare was urgently required. It was the Education (Administrative Provisions) Act of 1907 which first provided the statutory basis for our School Health Service. Since that time the service has steadily developed, with West Ham to the fore in many fields. The forthcoming Jubilee is a time when it is specially appropriate that we should look back, and I am sure that the reports of those earlier days would contain much of interest to our generation and would give scope for comparing the present with conditions existing here in those pioneering days. The Chief Medical Officer of the Ministry of Education, Sir John Charles, refers to the "foundations which were then so well and truly laid." The School Health Service has been developed to meet the special circumstances attending the life of the school child, and from the earliest days the attitude of the school doctor has been essentially that of a practitioner of social medicine. The present function of the service is "that of discovering the first signs of failure of physiological adaptation which precedes the stage of pathological lesion, and this pre-supposes a greater familiarity with what constitutes normality, which is recognised not as a point in a scale but as a range." This point has been stressed by our paediatrician, Dr. Hinden, in one of his reports. 93 Examination of School Leavers. The medical inspection at the age of fourteen enables the medical officer to give an opinion about the type of work for which the boy or girl is physically suited. If it is found that a child has a specific "unsuitability" for particular types of work the fact is reported to the Youth Employment Officer on an appropriate form and, in addition, a letter is sent amplifying the reasons. These inspections bring together child, parent, medical officer and often the teacher, and provides an opportunity for stimulating an interest in health matters as well as allaying unnecessary anxiety. Besides health education they also have the function of health assessment and detection of faults. Special Examinations. Special Inspections are also carried out at any time if for any reason a parent, teacher, school nurse or health visitor wishes to have the medical officer's opinion. In addition to this work children who have been referred for treatment or observation are re-examined at intervals. It is interesting to note that, at periodic medical inspections, only 6.77 Per cent of our children have a defect found to require treatment. In 1955, the number was 7.8 per cent. Apart from defects of vision, excluding squint, the percentage found to require treatment was only 3.3. The work done by School Nurses and Health Visitors. School doctors are assisted in their work by school nurses and health visitors. The work of the school nurse and health visitor includes (1) preparation of pupils for medical inspection, i.e., weighing and measuring, vision testing; (2) assisting the school medical officer at medical inspection, e.g., obtaining history from parents, details of home conditions, etc. (3) routine inspections of pupils for cleanliness; (4) assisting at minor ailment clinics; (5) home visitation. The school nurses Inspect all children in school every term for personal hygiene. The nurses inspections of personal hygiene are the basis of the "cleansing" scheme. There has been great progress since the early days of this work, but even to-day a small percentage of children are found to be "dirty" and the work of Inspection must, therefore, go on. This work of the school nurse is health education in its most practical form. Schools have played an important part in the raising of general standards of hygiene. Health education in the schools is largely a responsibility of the teachers, but the medical officers and nurses also have an important role to play. This aspect of education is most important, not only in the interests of the children themselves, but also because of their future influence as parents of the next generation. 94 The school nurse has many other functions to perform. By regular visiting of her area she can often detect abnormal environmental conditions long before they have resulted in departure from health which might otherwise be detected only at periodic medical inspections. The mental health of the child is receiving particular attention in the School Health Service and both the school doctor and the school nurse can often detect psychological aberrations in their earliest stages. There is a great future for this kind of work in the Education and School Health Services. Handicapped Children. In dealing with handicapped children the service now shows a greater pre-occupatlon with ensuring that handicap does not prevent the child from receiving an education appropriate to his age, ability and aptitude. The early ascertainment of handicapped pupils is one of the most important functions of the School Health Service. The education authority is responsible for the ascertainment of all handicapped pupils over the age of two years who require special educational treatment. The principle of special educational treatment for certain children constituted a major advance. Later it will be shown what is done for the ten categories of handicapped pupils. The effect of the National Health Service Act, 1946, on the School Health Service. Not withstanding the National Health Service Act, 1946, the School Health Service is established more firmly than ever. The reason for this is that the School Health Service, as its name implies, is much more than a medical service, and is very closely linked up with the educational life of the child. The first effects of the National Health Service were, however, unfortunate because the demands of other sections of the community for free treatment caused a curtailment of certain facilities for schoolchildren. Difficulties in the supply of glasses have been overcome and there has been an improvement in the supply of school dental officers, which is referred to in the report of the Senior Dental Officer. The Chief Medical Officer of the Ministry of Education in his Report for the years 1954 and 1955 mentioned the attainment by the School Dental Service for the first time of a total equivalent of over 1,000 whole-time officers and referred to it as a "milestone in its history". Continuous consultation and co-operation between the authority and the various bodies administering the National Health Service is required to ensure that the scheme for the treatment of schoolchildren is comprehensive and efficient. Consultants of the Regional Hospital Board are employed for part of their time in the local authority premises which ensures easy referral by medical officers to them of cases about whom they are concerned. The school medical officers refer large numbers of children requiring specialist attention to these consultants, subject, except in certain agreed conditions, to the general practitioners; agreement. Copies of the reports are sent to the practitioners; likewise, a number of hospitals send to the school medical officer copies of reports to the general practitioner on children who have been in-patients. 95 The contribution of the School Health Service to social medicine. The sphere of influence of the School Health Service spreads for beyond the school into the community. The service is particularly well placed to help both children and their parents. The school nurses and health visitors visit the homes and families of the children and become thoroughly acquainted with them. The school doctors meet the parents in schools and clinics and at the clinics they can spend a sufficient amount of time investigating the problems of individual children; they have the great advantage of knowing about the home life from the health visitor, and of his work and behaviour in school from the teachers. Furthermore, they have the services provided by the local education authority and of the National Health Service. This account of the welfare of schoolchildren can suitably be closed by quoting a Principal School Medical Officer at the close of a long career in local government service, "After a long experience in the public health service, which I suppose gives one some right to assess relative values, I have no hesitation in saying that in the whole local government public health service no single branch 1s of greater importance to, and has played a greater part in, the building up of the health of. children and young people of this country than the School Health Service in its many branches." Medical Inspection Rooms. The Standards for School Premises Regulations, 1954, do not specify separate accommodation for medical inspection purposes, merely requiring that suitable accommodation shall be immediately available at any time during school hours for the inspection of pupils by medical officers, dental officers and nurses. The accommodation for such inspection shall be well and suitably lighted and heated, and should be conveniently accessible to a closet, and every room provided for such purposes shall include a wash-basin with a supply of hot and cold water. In a number of the older schools medical rooms are not available, and consequently inspections have to be carried out in classrooms, school libraries, film or other rooms. Every effort is made to make the parents, children and medical staff comfortable. In the newer schools a medical suite is included. The standards for School Premises Regulations have sometimes been criticised for hot prescribing a medical room for new schools, but the Ministry have stated that the Regulations could not in any sense be held to condone unsatisfactory conditions. The purpose of the school medical Inspection is not merely the detection of physical defects in the child. It gives an opportunity of gaining the confidence of the parent and child, but to ensure this it is essential that the Interview should be carried out in a quiet, unhurried, efficient manner, in surroundings that enable the doctor, nurse, parent and child to give their attention to one another. The interview is confidential and the surroundings should ensure that it remains so. Generally speaking, the conditions in most of the schools are quite satisfactory. 96 HYGIENE OF SCHOOL PREMISES The Standards for School Premises Regulations, 1954, lay down scales of provisions for cloakrooms, washbasins, water closets and urinal stalls and, in the case of county and voluntary secondary schools, changing rooms and showers. In all county and voluntary schools suitable accommodation should be available for dining and every school should have sufficient and suitable kitchen accommodation. Sufficient and suitable cloakroom, washing and sanitary accommodation other than that provided for the pupils should also be provided in every school for the use of the teaching staff and the staff employed in the School Meals Service. Medical officers when visiting schools for medical inspection do not confine themselves to seeing the children but interest themselves in general hygienic arrangements and the condition of the sanitary accommodation in so far as these may affect the health of the pupils and staff. For a number of years now the medical officers have conducted a review of the hygiene of each school at the completion of their periodic medical inspection. Although the detailed reports for each school are kept In the central office any observations made by the medical officer are sent to the Chief Education Officer whenever necessary So that he can consider how far and at what stage it may be practicable to implement any recommendations. Minor matters may be remedied as they arise but certain improvements can only be implemented by Inclusion in long-term plans. Liaison between the Education Department and the Borough Engineer enables the medical officers' recommendations to be interpreted into practical improvements to the school buildings or to the various services accommodated in them. During the year 6l reports were made and dealt with in this way. In January last year the Primary Education Sub-Committee recommended agreement in principle to the closing of spray baths in all schools with the exception of Elizabeth Fry and Gurney Special Schools. It was gratifying to believe that the cleanliness of the children had improved sufficiently to make this possible. Food Hygiene. The Food Hygiene Regulations, 1955, came into operation on 1st January, 1956, and modified and extended the hygiene requirements contained in the Food and Drugs Amendment Act, 1954. They apply to the supply of food In the course of a business, which is now defined so as to include schools as well as canteens, clubs, and other Institutions, and therefore they are of much interest to the local education authority. As a measure for the maintenance of good standards of food hygiene they will be welcomed. Among the Regulations, those which are of special importance from, the school meals service point of view are those relating to: 1. the personal cleanliness of the kitchen staff; 2. sanitary conveniences; 3. provision of water supply; 4. provision of wash hand basins with hot water; 5- facilities for washing food and equipment; and 6. the temperature at which certain foods, which are particularly liable to transmit disease, are kept in food premises. 97 Personal Hygiene. The work of the school nursing staff was referred to in the section on the welfare of school children. One of their duties lies in the routine cleanliness surveys which are carried out each term. The numbers found to be infested at these surveys are augmented by others who are discovered at periodic or special medical inspections. The numbers found at periodic medical inspection are very few, the main reason being that parents receive notice of this examination and therefore have some time to see that their children are presented in a satisfactory condition. In the case of cleanliness or hygiene surveys carried out by the school nurses neither the parents nor the children receive notice of the inspection, and the pupils are found in the condition in which they habitually attend school. While the responsibility of cleansing is upon the parents, children found to be infested are followed up until the school nurse is satisfied that they are clean. During the year 63,787 inspections were made at these cleanliness surveys and 4-57 instances of infestation found. On the basis of a school population of 29,453 this gives a proportion of uncleanliness of 1.55 per cent which compares with 2.59 per cent in 1955 calculated in the same way on a school population of 29,487. This number refers to individual children, because however many times a child is found dirty in the year, it is only recorded as one case. There are many instances of recurrent infestations in the same children, and these persistent offenders provide the School Health Service with one of its most pressing problems. Infestation in such children can never be eradicated until the whole family is freed from it. The procedure for dealing with infestation in school children adopted by the Education Committee in 1953 and described in detail in the annual report for that year, was continued throughout 1956. The following figures relate to the work done during this period:- Total number of individual pupils found to be infested 457 Total of individual pupils in respect of whom cleansing Notices were issued (Section 54(2) Education Act, 1944 176 Total of individual pupils in respect of whom cleansing Orders were issued (Section 54(3) Education Act, 1944 12 It is interesting to record that, although 12 cleansing Orders were issued, only 6 children were compulsorily cleansed at the Treatment Centre. Experience shows that the force of the Cleansing Notice has the effect in many cases of making the parents realise their responsibilities so that, even although it was necessary to issue a cleansing Order, by the time it is in the parents hands a number of the children have been satisfactorily cleansed. During the four years under review the percentage of uncleanliness has dropped from 4.6 in 1953 to 1.55 in the present year. There was a reduction of 99 cleansing Notices and 36 cleansing Orders issued during the year compared with the previous year. Twenty-seven cases had a second Notice issued during the year, and 3 cases a third Notice. We refer to these as "careless families". There have been a number of indications, however, of the salutary effect of the cleansing campaign upon the parents, and fathers in particular have realised, often for the first time, the condition into which their children have been allowed to fall and have taken active steps to remedy the situation. 98 To combat this social evil no one has done more than the school nurse, who is also often the family health visitor, and interested school teachers have rendered invaluable help. It is a thankless task, but any relaxation of vigilance would gradually give rise to the former bad state of affairs. It must be difficult to keep children clean in overcrowded, sub-standard houses, and much credit is due to the mothers in that the majority of children living under these conditions are clean. Following Up. This continues to be an important function of the School Health Service, and is carried out by the school nurses and health visitors. Only the more important cases are, however, followed up. The School Health Service frequently requires the nurse to visit the children's homes to obtain reports of various kinds and this is welcomed as an excellent opportunity of getting to know really intimately the families for whose welfare they are concerned. Much valuable social work is carried out by the nurses by giving help and guidance in a variety of ways to families needing it. Reports on home conditions chiefly in cases of asthma, bronchitis and rheumatism required by hospital specialists are often prepared by the school nurses following home visits. During the year the school nurses paid 1,577 home visits in this way. This number includes 868 visits in connection with the Medical Research Council's controlled B.C.G. trial with school leavers mentioned on page 114. RESEARCH AND INVESTIGATION Only a brief statement will be made under this heading this year. A joint committee of the Institute of Child Health (University of London), the Society of Medical Officers of Health, and the Population Investigation Committee of the London School of Economics have been following the health, growth and development of 6,000 children born in the first week of March, 1946. These are drawn from all social classes and from all parts of England and Wales. Certain findings were included in the report for 1955. It is hoped to keep the children in the survey until the end of the Primary school period. The joint committee have stated "Such an opportunity to study growth is unique, and we are confident that the importance of the results for child health will justify the amount of work involved in carrying out the survey" and have recorded their gratitude to the health visitors and school nurses for the work they have done. During 1952 and 1953 the medical officers carried out 25 and 21 survey examinations respectively, but none has been carried out since. The number of reports completed by the school nurses during 1952, 1953, 1954 and 1955 were 25, 68, 24 and 23 respectively. No reports were made in 1956. A review by medical officers and school nurses should have taken place in October, 1956, but some areas requested that the review should be postponed until January, 1957: therefore no examinations were carried out by medical officers and no visits undertaken this year. 99 TREATMENT Ringworm One case of ringworm was treated during the year. It was a single lesion treated at a minor ailment clinic by fungicidal ointment. The reduction in the number of children with ringworm is general and there is a good deal of evidence to show that scalp ringworm is a declining disease. The figures for previous years are given for comparison Year Total Number Received X-ray Treated Treatment 1946 24 16 1947 15 9 1948 7 6 1949 2 1 1950 4 1 1951 5 2 1952 3 - 1953 - - 1954 1 - 1955 1 - 1956 1 - The incidence in 1956 was 0.0033 per cent. It is interesting to compare this very low incidence with that of twenty-eight to thirty years ago. Year Number of Schoo1 Incidence Cases Population 1926 117 50,279 0.23 1927 84 49,660 0.17 1928 78 48,939 0.20 Scabies The incidence of scabies remains low. In recent years there has been a general reduction in the number of children with this disease. This year, however, fourteen cases were discovered as compared with six cases in 1955. This gives rates of 0.04 and 0.22 per cent of the school population. In 1954 only one case was discovered being the smallest over recorded. The increase during the last two years shows that we must be ever vigilant. Scabies is treated at the Treatment Centre. Previous annual reports have shown the steady decline of this infestation from the war-time peak of 2,750 cases in 1942. It is interesting to compare the present incidence with that of the middle years between the wars when the rates were also low. To this end the following table has been compiled:- Year Number of Cases School Population Incidence 1926 66 50,279 0.13 1927 82 49,660 0.16 1928 100 48,939 0.22 1951 25 28,178 0.09 1952 35 29,139 0.12 1953 3 29,653 0.01 1954 1 29,707 0.003 1955 6 29,487 0.02 1956 14 29,453 0.04 100 Impetigo This skin disease is very contagious. The lesion is first vesicular, later it becomes dry with the formation of yellow "stuck on" crusts. Different forms are described. It is contagious and auto-contagious and from the original site it can be spread to any part. Treatment at the clinics is quickly curative, and the contagious character of the lesion must receive attention. The number of cases treated at the clinics this year was 78 being an increase of 12 on the previous year. THE WORK OP THE MINOR AILMENT CLINICS There are three minor ailment clinics in the Borough, their location being as follows:- Balaam Street School Clinic, Open 9 a.m. to 12.30 p.m. Balaam Street, Plaistow, E.13. Monday to Saturday Rosetta School Clinic, do. Sophia Road, Custom House, E.l6. Stratford School Clinic, do. 84 West Ham Lane, Stratford, E.15. A medical officer is in attendance at Stratford School Clinic and Rosetta School Clinic on Monday and Thursday mornings from 9 a.m. to 12.30 p.m. and at Balaam Street School Clinic on Tuesday and Friday mornings from 9 a.m. to 12.30 p.m. One of the main difficulties to be faced by the school medical officer is that in the school he frequently has neither sufficient time nor suitable accommodation to examine some children as thoroughly as he would wish. The minor ailment clinic, serving as it does a group of schools, becomes the centre of school health work in the area and Is used for the examination of many different kinds of cases. These clinics have always been well used for the treatment of minor ailments and, although attendances are still falling, a large number of children still come to them referred mainly by head teachers. The treatment of minor ailments at a school clinic is well established as one of the most expeditious and comprehensive means of dealing with many troublesome conditions and of preventing further impairment of health. The cases are seen by the medical officers on their clinic sessions, and the bulk of the treatment is carried out by school nurses. Although many of the conditions seen may be regarded as trivial their prompt treatment saves a good deal of minor disability and, in a number of cases, prevents a simple lesion becoming a major one. These clinics enable children with all kinds of minor ailments to be treated at a time and place which reduces to a minimum the loss of school time. Continuity of treatment is ensured through the close association of this work with the schools. The chief conditions treated fall under three main headings:- 101 Minor skin troubles of various kinds. These include the triad of ringworm, scabies and impetigo, together with a variety of other skin conditions. Ringworm of the scalp has dropped to negligible proportions; scabies has a very low Incidence, and Impetigo remains within bounds, so to speak. Many children are affected each year with plantar warts. The Incidence is three times greater among girls than among boys, and the incidence increases with age in both sexes. It is at its maximum between 11 and 14 years. Similarly many children attend the minor ailment clinics in the summer with ringworm of the feet. This is a very troublesome condition and treatment is prolonged. Stress is laid on preventive measure. Minor ailments of the eyes. These are mainly external diseases such as various forms of conjunctivitis, sore eyelids, small cysts of the eyelids, minor injuries and foreign bodies. In a few cases external eye diseases indicate eyestrain or debility, or unhygienic surroundings. Eyestrain can cause tired eyes, and these are rubbed more than usual; hence inflammation results. With a general Improvement in living conditions, in hygiene generally, and in the health of the children these diseases of the external eye are seen much less frequently than formerly and when they are met with they are not nearly so severe as they have been in the past. Some of these diseases of the external eye are, however, according to their nature and severity, sent to the ophthalmic clinic in West Ham Lane for specialist attention. In most of the cases they can be dealt with at this clinic but occasionally the specialist sends them to hospital for treatment. Minor ailments of the ears. These consist of small bolls In the outer passage and can be very painful, the accumulation of wax in the ears which Is the most common cause of hearing loss, the slighter degrees of earache and discharging ears, and finally, foreign bodies (chiefly met with in the younger children). As with minor eye diseases these conditions are much less common than formerly: also they are not nearly so severe. The more serious conditions considered to require specialist attention, are referred, subject to agreement with the child's family doctor, to the ear, nose and throat specialist. The aural specialist has noted a marked reduction in the number of chronic ear diseases In the borough. Miscellaneous conditions. These form the bulk of the cases treated and consist of a very mixed collection such as bruises, sprains and strains, abrasions and lacerations, boils, whitlows, chilblains, cuts, sores, and minor injuries of various kinds. The above cases form the main mass of work at minor ailment clinics. They are treated by the nurses under the supervision of the medical officers. The following figures give the number of cases which were seen at the clinics during the year for:- Skln Diseases 943 External Eye Diseases 173 Minor Ear Defects 153 Miscellaneous Defects 1,273 Total: 2,542 102 The total number of children who attended the three clinics for all purposes was as follows:- Clinic New Cases Stratford 1,056 Balaam Street 1,155 Rosetta 1,487 Total: 3,698 It is, of course, necessary for many of the children to attend on more than one occasion, and medical officers differ In the number of times they wish their cases to attend the clinic. Some Indication of the volume of work carried out at these clinics will be obtained from the following tables:- Clinic No.of Attendances Stratford 3,680 Balaam Street 5,135 Rosetta 6,823 Total: 15,638 This is a decrease from last year's figures. During the post-war years there has been a steady decrease in attendances, with the exception of 1951, as the following figures show:- 1946 41,746 1952 26,160 1947 38,443 1953 22,011 1948 36,165 1954 18,760 1949 33,221 1955 17,751 1950 28,605 1956 15,638 1951 32,248 It is interesting to note that the attendances are still falling despite an Increase in the number of cases treated during the year (200). The decline in the number of attendances during the past few years has been due to a decline in the severity of many of the conditions treated and also to earlier treatment; and perhaps also to an increasing tendancy to use the services of the private practitioner and the hospitals which are available through the National Health Service. REPORT ON THE WORK OF THE OPHTHALMIC CLINIC by Miss A.A.S.Russell, M.B.,Ch.B.,D.P.H.,D.0.M.S. The work of the ophthalmic clinic continued as in previous years. As usual a large number of refractions were carried out and 1,653 pairs of glasses were ordered, but many more children were examined who either had suitable glasses or did not require them. 103 In addition to the children having a full eye examination, many others are reinspected and a number of children make several attendances. The total number of attendances during the year was 7,046, and of these 6,110 were made by school children and 936 by children under school age. Where operative treatment was considered necessary the children were admitted to Whipps Cross Hospital and during the year 77 squint operations were performed on 71 children referred from the West Ham Lane Clinic. Twentyfour of these were on children under school age. The results of operation combined with treatment In the orthoptic department were very satisfactory. The work of the orthoptic department has been carried out by Mrs.Palfreman. There were 2,339 attendances including 355 from children under school age. Of these there were 6l new patients under school age and 110 new patients among school children, Mr.Lauder continued with his duties as full time optician and he dispensed 1,150 prescriptions for new glasses; while 503 prescriptions were taken to outside opticians. In addition to measuring and fitting new glasses Mr.Lauder deals with a^large number of repairs for broken glasses and many of the minor repairs or adjustments are carried out In the clinic. The number of attendances in his department amounted to 4,837- Defective Colour Vision. The Confusion Chart Test designed by Professor Shlnobu Ishihara of Tokyo University and known as the Ishihara Test, is considered a satisfactory test for general use in the School Health Service, and all the medical officers are provided with an album of plates. This test has been used in West Ham for many years but has been limited to pupils attending grammar and technical schools; for boys who have obtained Sea Training Scholarships, and for those pupils who propose entering services where correct colour discrimination is necessary. In 1957, however, testing will be extended so as to cover the pupils in the secondary modern schools. There are considerable differences between Individuals in their ability to distinguish one colour from another. In the great majority of cases defective colour vision is congenital and although women are frequently carriers of the defect, without they themselves necessarily having defective colour vision, the incidence is very much greater in males. Since it is a severe handicap in certain occupations It is clearly in the child's Interest that it should be discovered before his career is decided. The test, which is easily explained and understood and quickly carried out is given at the age of 14 years and can be done in an ordinary room In good daylight. Many cases, when informed of the defect, state that they are aware of It and often explain in various ways how they became aware of it. When a defect is found the parent is advised and the head teacher informed. The colour defective boy may be at a serious disadvantage in any profession or trade which demands accurate colour discrimination and because of this the test is given In good time to prevent boys from preparing for occupations for which a colour vision defect might render them unsuitable. The parent is told that the child has difficulty in recognising and matching colours, and that he should manage well enough in ordinary life. Unfortunately, it cannot be cured but It will get no worse. The parent would not wish to waste time and energy in having the boy trained and then find that he was not really suitable for the job because of defective colour vision. It is also important that a boy with colour defect should know about It as early as possible. Advice regarding the occupations that are closed to him any save him a bitter disappointment. 104 Among the various industries in which colour discrimination is important are the following - textile dyeing and printing, electrical engineering, paper making, printing and engraving; photographic trades, printing ink manufacture, paint making and mixing, decorating, chemical laboratory work in various industrial laboratories. In some grades of the Royal Navy and Marines, the Merchant Navy, the Royal Air Force and the Railways, normal colour vision is required. The Ishihara Test is not considered sufficiently accurate in these cases and a special lantern test, such as with the Edrldge-Green Lantern, should be carried out. It should be appreciated, however, that the Ishihara test errs on the safe side In that it will detect degrees of defective colour vision which might not be sufficient to exclude the boy from a particular occupation where normal colour vision is required. At the examinations held at the grammar and technical schools during the year the following results were obtained:- Number Colour Percentage examined Defective Colour Defective Boys 822 49 5.96 Girls 826 1 0.12 The following figures relate to the findings during the last eleven years: Number Colour Percentage examined Defective Colour Defective Boys 9,131 498 5.45 Girls 9,255 11 0.11 During this period the boys were examined by the same medical officer, and the girls by the same medical officer except during the last three years when a second medical officer assisted. Recommendations of the Faculty of Ophthalmologists on this subject are worthy of mention- "a) It is desirable that all children should be tested for Colour vision some time during their school career. "(b) Primarily, all children should be tested by the Ishihara method in good daylight, and all failures should be retested by a lantern test. "(c) Any child who is colour blind should not be regarded as a disabled person." The Main School Medical Record card (Form 10M) has a space (13) for the recording of "colour vision" and the school-leaving medical report to the Youth Employment Service also notes this subject and, if the child is defective, the medical officer Indicates that the pupil should not enter any occupation requiring normal colour vision. Defective colour vision does not render a child disabled under the Disabled Persons (Employment) Act. 105 TONSILLECTOMY FIGURES The Ministry of Education state that there is evidence of considerable underreporting by hospitals to local education authorities of children who have had tonsillectomy. As there was need for more accurate information, all principal school medical officers in England and Wales were asked in September, 1955, to arrange for their medical officers, throughout 1956, during their examination of children at periodic medical inspections, to note on the school medical record cards which children had already undergone tonsillectomy. About a third of the total school population is examined at periodic medical inspections each year so, by the end of 1956, for each county and county borough, the percentage of boys and girls in the age groups examined who have had the operation would be known. It would then be possible to make a better comparison between the tonsillectomy rates for different areas and to investigate the reason for the high rates. The Medical Research Council's Committee for Research on Social and Environmental Health has the subject under review. The following figures relate to the findings during 1956:- Number examined No. who had tonsillectomy performed Percentage BOYS: Entrants 1,001 70 6.99 Second Age Group 838 205 24.46 Third Age Group 1,205 331 27.47 Additional Periodic 849 211 24.85 GIRLS: Entrants 955 52 5.44 Second Age Group 729 167 22.90 Third Age Group 1,342 371 27.64 Additional Periodic 674 163 24.18 Combined Totals: 7,593 1,570 20.68 106 REPORT ON THE WORK OF THE AURAL CLINICS by C.J.Scott, M.B., Ch.B., D.L.O. I am glad to report that the Ear, Nose and Throat clinics in the Borough of West Ham during the past year have been well attended, and the special attention paid by the medical officers of the borough to detect cases of deafness in children has been most successful. This problem is now receiving very careful study in the borough in all age groups for children. The Audiology Unit is now well established to detect and to treat the early cases of congenital deafness. In addition, the usual number of children have been presented for tonsils and adenoids operations and these have been carried out at Whipps Cross Hospital. A considerable number with chronic sinusitis have also been admitted and treated. The number of chronic mastoids is now much less but several have required a radical form of surgery in the past year. The Ear, Nose and Throat clinics are administered by the West Ham Group of the Hospital Management Committee but are held on the West Ham Education Committee premises as follows:- Stratford School Clinic, Monday and Tuesday mornings 84 West Ham Lane, E.15. 9 a.m. to 12 noon Rosetta School Clinic, Friday mornings Sophia Road, Custom House, E.l6. 9 a.m. to 12 noon HEARING OF SCHOOL CHILDREN. The methodical testing of school children by the gramophone audiometer ceased in November, 1952, when the audiometrician resigned her appointment, but in the autumn of 1954 a school nurse was sent to one of the Divisions of the London County Council for' training, and for the last two months of 1954, the whole of 1955 and the first half of this year was engaged for four sessions a week in audiometric work in the schools. Her work was efficiently carried out and It was found that gramophone audiometry was well within the competence of a good school nurse. The nurse found the survey work an Interesting addition to her other duties and she had the advantage of being already well known to many of the children whom she had to test. In the early part of 1955 Miss A.Smart, an audiometrician, was appointed and commenced duty on 21st February. Her work Is divided between the School Health Service and the Regional Hospital Board, giving approximately half her time to each service. Besides testing the children in the schools with the gramophone audiometer, the audiometrician also attends the ear, nose and throat clinics with the audiologlst, the deaf school, spastic unit and the Audiology Unit. Her specialist knowledge of pure-tone testing is taken advantage of in certain of these centres. 107 As mentioned In previous reports a fact that has emerged In this work Is that, although numbers of children are found with varying degrees of unsuspected hearing lass, this is rarely of such a degree that special educational treatment in a special school is necessary. After treatment, either by a school medical officer at a minor ailment clinic or by the specialist at our special clinics, or at an aural department of a hospital, a favourable position in class, with perhaps, a hearing aid and instruction in lip reading is all that is required In the way of special educational treatment. A complete round of the primary schools was finished In July of this year and the school nurse has not done any testing since. In 1952 it was noted that some new technical advance would be needed and that the trend had been away from gramophone audiometry to pure-tone audiometry. In 1955 It was hoped that a start would be made with pure-tone screening In 1956. Although by the end of the year screening had not actually taken place, individual testing had been carried out. The Medical Research Council's Committee on the Educational Treatment of Deafness has recommended the adoption of the sweep-frequency method. Before giving the figures relating to the work done during 1956 it should be mentioned that the school medical officers, as for many years past, refer any cases of suspected deafness to the aural specialist and If he considers that there is any degree of deafness present a pure-tone audiogram is taken. Should the audiogram confirm a loss of hearing sufficient to Justify special educational treatment the necessary steps are taken to ascertain the child as deaf or partially deaf and appropriate action is taken. The following figures relate to the findings during the year:- No. of children No. of children No. referred to tested retested School Medical Officers Gramophone Audiometry 3,298 1,138 26l Pure-tone Audometry 164 3 24 The pure-tone audiometer produces a range of tones corresponding to all the tones produced by the otologist's tuning forks, and it produces those tones in a wide scale of measured intensities of sound, ranging from the threshold of hearing to the threshold of feeling. By this means the audiometrician can not only rapidly ascertain what tones the child can hear, but also how loud they need to be before they are heard, thus enabling her to plot a chart or audiogram which illustrates graphically the full extent and characteristics of the hearing loss. This audiogram provides valuable data for diagnosis, a useful indication for therapy, and a reliable record for use in consultation or in re-examlnation at a later date. In re-examinatlon over a period the Audiogram is most valuable, for it is the only scientific means by which an audiometrician can rapidly and accurately measure the extent to which the child's hearing has improved or deteriorated. 108 1956 AUDIOMETRIC SURVEYS - COMPLETED INVESTIGATIONS Defect For treatment For observation Refused investigation Removed from area before investigation completion No action required Totals Minor Ailment Clinic E.N.T. Clinic Hospital General Practitioners Assistant Medical Officers E.N.T. Clinic Recommended to sit In favourable position Cerumen 11 - - - - - - - - - 11 No hearing loss - - - - - 3 - - - 82 85 For tonsil and adenoid dissection - 2 - - - - - - - - 2 Conductive deafness - - - - - 5 3 - - - 8 Eustachian tube blockage - - - 1 - - - - - - 1 Mixed deafness - - 1 - - - 1 - - - 2 Deafness due to mechanical obstruction - - - - - - - - - - - Perceptive deafness - - - - - - 1 - - - 1 Deafness: Cause not known - - 2 - - 2 3 - - 17 24 Total deafness- one ear - 3 - - - - - - - 2 5 Catarrhal deafness - 5 2 1 - - - - - - 8 Deafness due to perforated ear drum - - 1 1 6 - - - - - 8 High frequency- deafness - - - - - 1 - - - - l Low frequency deafness - - - - - 1 - - - - l Otorrhoea - - - 1 - - - - - - l Doubtful defect - - - - - - - 2 10 - 12 Grand Totals: 11 10 6 4 6 12 8 2 10 101 170 109 ORTHOPAENIC AMD POSTURAL DEFECTS. As in previous years children with the more severe degrees of these defects were referred to the orthopaedic surgeons at the Children's Hospital, Plaistow; Queen Mary's Hospital, Stratford, and various other hospitals. In many cases insoles or wedging of the shoes were prescribed, while in a few cases orthopaedic operations were carried out. In certain cases, when specialist opinion is helpful, as in some handicapped children, particularly those in the special school, it is willingly given by the specialists. Following the establishment of the Council's own physiotherapy service at the beginning of 1952, 126 children were treated at Forest Street, Grange Road, Maybury Road and at the Elizabeth Fry Special School during the year. Cases known to have been treated outside the Council's scheme numbered 115. Cases so treated have progressively fallen from 311 in 1952 to 115 in 1956. Four children were also known to be in-patients in various hospitals. In accordance with the National Health Service arrangements, surgical boots and orthopaedic apparatus are provided by the hospitals when needed. PHYSIOTHERAPY. Mrs.A.M.Tootell, the superintendent physiotherapist, continued her work on a part-time basis. She attended three full days a week, approximately 7® per cent of the time being devoted to the School Health Service. In addition an extra 126 hours were worked during the year which was necessitated owing to resignations of other physiotherapists. Mr.Bouldon resigned on 12th May, 1956, and Miss Forrest on the 12th December, 1956. Miss Barnes commenced duty three days a week on 3rd December, 1956. The local authority clinic premises are equipped, for artificial light therapy and treatment is given in Forest Street, Grange Road and Maybury Road Child Welfare Clinics. At these clinics both school children and pre-school children were treated. The following programme was in operation during the year Mr.Boulton's sessions being discontinued after the 7th May. Superintendent Physiotherapist Physiotherapist (Mr.Boulton) Physiotherapist Miss Forrest) MONDAY A.M. Grange Road Clinic Maybury Road Clinic Spastic Unit P.M. Spastic Unit Spastic Unit Forest Street Clinic TUESDAY A.M. - Spastic Unit Spastic Unit P.M. - Spastic Unit Spastic Unit WEDNESDAY A.M. Spastic Unit Spastic Unit Forest Street Clinic P.M. Spastic Unit Maybury Road Clinic Spastic Unit THURSDAY A.M. - Spastic Unit Spastic Unit P.M. - Maybury Road Clinic Spastic Unit FRIDAY A.M. Grange Road Clinic Spastic Unit Spastic Unit P.M. Spastic Unit Spastic Unit Forest Street Clinic 110 Children are usually referred to the physiotherapist by the local authority medical officers. An increasing number of general practitioners refer cases for breathing exercises, foot exercises and ultra-violet irradiation. Specialists at a number of London hospitals also wish cases, chiefly asthma and bronchitis, to be treated at the local clinics to save the parents and children the trouble and time of travelling long distances. The consultant paediatrician and the ear, nose and throat specialist refer cases from time to time. Children with the slighter degrees of flat foot, valgus ankles, knock knees and poor posture are treated by remedial exercises, mainly in the form of exercise classes; massage is also given when necessary. As has been mentioned in previous reports the classes for minor foot conditions yield satisfactory results, and this lends support to the view that these conditions, if dealt with in the early stages, can be more easily remedied and probably spared the need for later treatment by an orthopaedic surgeon. Usually only the more severe cases are referred to an orthopaedic surgeon and for the past five years there has been a marked fall in the number of children so referred. Many cases of asthma, bronchitis, catarrh, and recurrent upper respiratory infection are given breathing exercises, modified according to the particular type of chest condition. A number of these cases, as also cases of general debility from many and varied causes, are also given general ultra-violet irradiation. Artificial sunlight, as this special form of irradiation is called is given by a special type of mercury vapour lamp. The lamps used are known as "Centrosol" which enable a number of children to be treated simultaneously in a group. All the above facilities, provided on premises which are easily accessible and well known to the parents and children, encourage acceptance of treatment at a stage when it may be really preventive. Much valuable work was carried out for many of the children at the Elizabeth Fry Special School and these, together with the children in attendance at the Spastic Unit, and those attending the Unit as out-patients, were treated in the well-equipped Unit. The physiotherapeutic services carried out consist of massage, manipulation and special exercises, and most of the children require individual treatment. In fact so much attention is given by the physiotherapists that they become familiar with the characteristic needs and responses of each individual child. It is time consuming work. Any of these children found to require ultra-violet irradiation are treated at the nearby Grange Road Clinic. Location of physiotherapy clinics and times of attendance Forest Street Maternity and Child Welfare Clinic, Monday and Friday 1.30 to 5.15 P-ni. Forest Gate, E.7. Wednesday 9 a.m. to 12 noon. Grange Road Maternity and Child Welfare Clinic, Monday and Friday 9 a.m. to 12 noon Grange Road, Plaistow, E.13. Maybury Road Maternity and Child Welfare Clinic, Wednesday and Thursday 1.30 to 5-15-P-m- Maybury Road, Plaistow, E.13. (Closed 7th May,1956) 111 The following figures relate to treatment given to school children during the year:- Number Treated Total number of Treatments given Forest Street Clinic Sunlight 170 3,311 Massage and Exercises Grange Road Clinic Sunlight 103 2,579 Massage and Exercises Maybury Road Clinic Sunlight 33 357 Massage and Exercises Elizabeth Fry Special School Massage and Exercises 38 6,671 HEART DISEASE AND RHEUMATISM. Prior to this year all conditions of the heart and circulation were grouped together, although separate statistics were available for the individual conditions making up the total. Code No.10 on the revised school medical record card which came into use on 1st January, 1956, is now labelled "Heart". During the year under review 24 cases were referred at periodic and special inspections for treatment and 100 for observation. This represents a decrease of 19 cases for treatment and an Increase of 34 for observation. These figures are much less than those recorded only a few years ago. The school medical officer, who may be the first doctor to see a case either at a periodic or special examination, has a good deal of responsibility. It is essential that an accurate diagnosis should be made, not only to ensure appropriate treatment for those with organic lesions, but also to avoid unnecessary restrictions for others. A clear distinction should be made between functional disorders and those of organic defect and, in the case of the latter group, between those of rheumatic and those of congenital origin, inasmuch as the action to be taken is quite different in the various categories. T An analysis of cases seen by the paediatrician for the first time during the year shows that only two children were found with a cardiac lesion. These were slight congenital lesions of no significance and not requiring any modification in the school curriculum. Experienced observers are unanimous in regarding acute rheumatism as a disappearing disease which has changed its type. The number of children with cardiac involvement shows a steady decline, which seems to indicate that the disease, in addition to being less wide-spread, is also becoming less severe and the cardiac complications are becoming milder. As Dr.Hinden mentions in his report "Even a few years ago rheumatic fever and its sequal, rheumatic heart disease, was responsible for a substantial amount of invalidism. The disease is now less prevalent, ahd less severe: so that even when it occurs it is usual for the child to make a complete recovery". 112 The rheumatic child should not suffer any unnecessary deprivation of a normal life and full education. The number of children on restrictions is extremely low. The motto should be "a minimum of Invalidism and a maximum of normality". No case of organic heart disease was recommended for heart hospital school but one child with this condition was admitted to Elizabeth Fry Special School during the year. REPORT ON THE WORK OF THE PAEDIATRIC CLINIC by E.Hlnden, M.D., M.R.C.P. The work of the consultative school clinics has continued on the same lines as in previous years; most of the children have been referred by the assistant school medical officers, with a few sent direct by general practitioners. There has been an obvious lessening in the number of children seen over the years. This is in line with the steady reduction in the infantile mortality rate, and both are reflections of the improvement in the health of the children. It is rare nowadays to see a child who Is suffering from malnutrition; we still do most with children who are much smaller and lighter than their fellows, but this Is due either to a personal idiosyncrasy of the child, or else to organic disease. It is hardly ever caused by defects in nutrition. Even a few years ago rheumatic fever and its sequel, rheumatic heart disease, was responsible for a substantial amount of invalidism. The disease is now much less prevalent, and less severe; so that even when it occurs it is usual for the child to make a complete recovery. Most of the children seen are suffering from disturbances of function - the behavious disorders. Mental defect also plays a large part in causing children to be referred. I should like to thank the Radiologist at St.Mary's Hospital, Plaistow, for carrying out x-ray examinations when necessary; the Pathologist at Whipps Cross Hospital for giving me laboratory facilities; the school doctors who have referred the children to me, and the family doctors who have sanctioned the referrals. The paediatric clinics are administered by the West Ham Group of the Hospital Management Committee but are held on the West Ham Education Committee premises as follows:- Stratford School Clinic, Thursdays from 1.30 to 5-15 P-m- 84 West Ham Lane, E.15. Rosetta School Clinic, Wednesdays from 1.30 to 5-15 p.m. Sophia Road, Custom House, E.l6. Towards the end of the year the clinics at Rosetta School Clinic were held fortnightly owing to reduction in the numbers referred. TUBERCULOSIS IN CHILDHOOD. The number of children in whom active tuberculosis is found remains comparatively small but has shown no marked trend of recent years. The number of children found to be suffering from tuberculosis was 14 in 1952 and the same number was found in 1953; while in 1954 and 1955 the number was 13 In each year. 113 A summary of the work of the-West 'Ham Chest Clinic in this respect has kindly been contributed by Dr.D.J.Lawless, the Consultant Chest Physician. Number of school children referred by school medical officers 12 Number of school children referred by general practitioners 103 Number of school children examined as new contacts 136 Number of school children found to be suffering from tuberculosis 15 The classification and disposal of the definite eases is set out below:- Respiratory Non-Respiratory Active primary pulmonary tuberculosis 4 Cervical glands 1 Tuberculous pleural effusion 5 Adult type of pulmonary tuberculosis 5 These 14 respiratory and 1 non-respiratory cases were admitted to hospital. B.C.G. VACCINATION. Prophylaxis against tuberculosis using the live vaccine containing B.C.G. (Bacille Calmette-Guerin) has been extensively practised since the vaccine was introduced more than thirty years ago. Although millions of such vaccinations have, by now, been carried out in various parts of the world, few controlled trials have taken place to assess the value of the vaccine as a preventive measure. In September, 195°, the Medical Research Council began a controlled clinical trial with school leavers. The main object of the research was "to determine with precision tuberculosis mortality arising in each of the groups of the trial in the years following their first examination for the trial". The object was to study what contribution B.C.G. vaccination might make to the problem of tuberculosis in children leaving school and entering upon the adult environment of work, i.e., a time of life at which the incidence of tuberculosis begins to rise in the highly industrial community of Britain. West Ham children in their final year at secondary modern schools and nearly all of whom were aged between 14½ and 15 years, took part in this investigation and the procedure was described in some detail in my report for the year 1953All children taking part in the trials, both positive and negative reactors to the Intracutaneous skin test, are being followed up for some years, and are being offered an annual x-ray examination and a repeat tuberculin test. The Medical Research Council Team visited West Ham in May, 1956, for the fourth inspection of Easter and Summer leavers of 1951 Approximately 868 home visits were made by the school nurses during 1956. So far, a satisfactory proportion of the boys and girls have remained in the trials and much of the credit for this is due to the keenness and good work of the school nurses and health visitors who visit the people (now young adults) once a year in an attempt to sustain their interest and to enquire about their health at the time of the visit and during the previous interval. This work, which has often involved making repeated visits, has been painstakingly carried out, and the interest of the volunteers and their parents in the trial and their response to the invitation for x-ray, are a reflection of the effort made. The trial is still in progress and the first progress report presenting preliminary results after each participant had been in the trial for two and a half years, with supplementary incomplete information up to four years, was issued in the early part of 1956. The following is an extract from the summary (as it relates to the full trial). 114 "The annual Incidence of tuberculosis In the tuberculin-negative unvaccinated group was 1.94 per 1,000; in the BC.G. vaccinated group It was only 0.37 Per 1,000 and in the vole bacillis-vaccinated group only 0.44 per 1,000 .... Each vaccine therefore conferred a substantial and similar degree of protection against tuberculosis over a period of two and a half years of adolescence. The protection conferred by each vaccine was evident soon after it had been given, and was still substantial between two and two and a half years after entry. Supplementary incomplete information up to four years suggests that the protection is maintained for this period If no participant in the present trial had been vaccinated a total of 246 cases of tuberculosis would have been expected within two and a half years of entry; if all the tuberculin-negative entrants had received B.C.G. vaccine a total of 111 would have been expected. This represents an expected reduction of 55 per cent in the total incidence of tuberculosis for the two and half years" The results are most encouraging, and the investigation has provided evidence of the efficacy of B.C.G. in preventing tuberculosis in adolescents. The object of the vaccination of the non-reactors to the tuberculin skin test is to produce in them a controlled primary focus of attenuated infection, with consequent development of acquired resistance, instead of allowing them to risk the dangers which are inseparable from natural uncontrolled exposure to infection by virulent tubercle bacilli In large numbers. The evidence suggests that B.C.G. vaccination affords a useful degree of protection to supplement all the other measures employed in the prevention and control of tuberculosis. The Medical Research Council has extended its thanks to all who helped and co-operated in the scheme. REPORT ON THE WORK OP THE SCHOOL DENTAL SERVICE INCORPORATING THE WORK OF THE MATERNITY AND CHILD WELFARE DENTAL SERVICE by S.Maxwell Young, L.D.S., R.C.S. During 1956, there was a gratifying increase in the stability of the dental staffing position, as the engagement of Mr.S.G.Osborne as a full-time officer, brought the number up to four full-time officers and as the part-time officers were of a less evanescent type than previously It was possible to do some long-term planning. All the dental clinics (except Maybury Road) have been functioning well, mostly on a full-time basis and this has made the routine Inspections of primary schools more feasible than hitherto. For instance, the schools attached to Forest Street Clinic are now being inspected for the second time In two years which, although not anything like ideal, is much better than it has been in the past. As outlined in the last report, the policy of the School Dental Service in the current staff shortage has been to offer routine inspection and comprehensive treatment to primary schools only and relief of pain and treatment on request to the others. With the slight improvement in the staffing position, it was felt that something more than this could now be done. Hence, in June, a pilot scheme was Introduced, whereby the upper three years of Stratford Grammar School were asked for "volunteers" for dental treatment at the clinic In West Ham Lane; this treatment was to be given in the early evening, so that no school time would be lost. A large number of pupils reported and the results were very gratifying. 115 This scheme has now been extended gradually to the older pupils of other grammar, secondary modern and technical schools in the hope that all children would leave school with a reasonably good dentition and the desire to look after their teeth in the future. We have had very mixed results overall, but, at least, a start has been made. The Maternity and Child Welfare part of our work has progressed, particularly in the case of the toddlers, many of whom return to the clinics for their routine inspection and treatment and it is very gratifying to the dental officers to see the good results of their work on these children, who have come to regard the dentist as an old friend and not the "bogey" man of their forbear. The response of the expectant mothers is, on the whole, disappointing. Par too many mothers who have been given appointments to the clinic fail to attend or attend too late in pregnancy for much to be done except the relief of pain. No doubt the Health Education of the mother-to-be is a task somewhat equivalent to the painting of the Forth Bridge. The demand for orthodontic work continues and it is very difficult to satisfy this without encroaching on the time and manpower needed for routine work. As orthodontics is, to a great extent, a post-graduate study, it would be of great assistance if dental officers were encouraged to attend post-graduate and refresher courses on this subject. Dentistry in general and orthodontics in particular is not static, and new techniques and knowledge are ever being brought into the light. It is therefore incumbent on everyone who has the interest of the service at heart to take advantage of this new knowledge for the benefit of the patient and the prevention of spiritual staleness. I would like here to thank the clinic and clerical staffs for their efforts during the year and to record, too, my appreciation of the help received from the medical officers, nursing staff and teachers. Location of Dental Clinics and times of Attendance. Forest Street Maternity and Child Welfare Clinic, Forest Street, E.7. Grange Road Maternity and Child Welfare Clinic, Grange Road, Plaistow, E.13. Rosetta School Clinic, Sophia Road, Custom House, E.l6. Stratford School Clinic, 84, West Ham Lane, E.15. 9 a.m. to 5.15 P.m. 9 a.m. to 12.30 p.m. 1.30 to 5.15 p.m. 9 a.m. to 12.30 p.m. 16th February, 1956. 1st October, 1956. 9 a.m. to 4 p.m. Monday - Friday Saturday (alternate weeks Wednesday Thursday Closed Re-opened Monday Tuesday Wednesday From 12th November, 1956. Monday - Friday 9 a.m. to 4 p.m. Sessions - 9.30 a.m. to 12.30 p.m. 1.30 p.m. to 4 p.m. Attendances variable owing to frequent changes in dental staff. Monday - Friday 9.a.m. to 5.15 p.m. Saturdays 9 a.m. to 12.30 p.m. 116 SPEECH DEFECTS. Miss R.Clarke, the senior speech therapist, continued her work at the main speech clinic at Greengate School; in addition two visits a week were made to the Spastic Unit. Miss A.Clarke, the assistant speech therapist, who commenced duty in November, 1954, was occupied mainly with work at the Spastic Unit at the Elizabeth Fry Special School. The Spastic Unit provides treatment for spastic children of all ages, particularly for those under seven years of age who are in the nursery class in the Unit. Physically handicapped pupils, including those with cerebral palsy, attending the special school and who need speech therapy are also treated at the Unit. The assistant speech therapist attends the Unit every morning and in the afternoons spends two sessions at the main clinic, two at the branch clinic at the Grange Road Maternity and Child Welfare Clinic, and one at Gurney Special School. It is important that these educationally subnormal children with speech defects should receive every help we can give them: on the whole they make slow but steady progress. Students from the West End Hospital for Nervous Diseases attend both the main clinic and the Spastic Unit. Much use has been made of the tape-recording machines both at the main clinic and at the Spastic Unit. At the main clinic a record of the children's progress is kept, and this can be used as a means of demonstrating to the child his own speech pattern, and its gradual Improvement during treatment. The record provides encouragement and an Incentive to steady perseverance. A permanent record is made at the Spastic Unit of the progress of each child by regular recordings every half-term. The special tape-recorder is most useful In demonstrating to parents in a most convincing fashion, exactly how much has been achieved by the patient work of the speech therapists. The close liaison between the speech clinics and other parts of the service, child guidance, nose and throat, paediatrlc and dental, which is so essential to its success has continued. Towards the end of the year a new scheme of reinspection of these children at the speech clinic was put into operation. Once a month the Chief Assistant School Medical Officer visits the clinic for this purpose and up to 24 children are seen at a session. The results have been most encouraging and much better than formerly when the children were relnspected by the school medical officers at their clinics or schools. The chief advantages are that the speech therapist is present and can give valuable information about the child and its progress: also the attendance is very good - well over 90 per cent attend with their parents. The number of children found suitable for speech therapy during the year was 50, and 6l were considered as no longer in need of treatment. Speech defects of a degree sufficient to warrant speech therapy do not commonly show themselves In very young children, and so the number of referrals from the Maternity and Child Welfare Department remained low. Last year an experiment was started of dealing with these pre-school children In a group and it proved successful. The group was continued this year and the senior speech therapist records in her report that - "it has been noticed that the majority of the children respond quickly to treatment at this age " 117 The following programme was in operation during the year:- Senior Speech Therapist Assistant Speech Therapist MONDAY A.M. Spastic Unit Spastic Unit P.M. Main Speech Clinic Main Speech Clinic TUESDAY A.M. Main Speech Clinic Spastic Unit P.M. Main Speech Clinic Branch Speech Clinic WEDNESDAY A.M. Main Speech Clinic Spastic Unit P.M. Main Speech Clinic Gurney Special School THURSDAY A.M. Spastic Unit Spastic Unit P.M. Visiting Main Speech Clinic FRIDAY A.M. Main Speech Clinic Spastic Unit P.M. Main Speech Clinic Branch Speech Clinic SATURDAY A.M. Clerical work and visiting (alternate mornings) Clerical work and visiting (alternate mornings) Location of Speech Clinics and times of attendance Main Speech Clinic, Monday and Thursday 1.30 to 5.15 P.m. Greengate School, Tuesday, Wednesday Cave Road, Plaistow, E.13. and Friday 9 a.m. to 5.15 p.m. Branch Speech Clinic, Grange Road Maternity & Tuesday and Friday 1.30 to 5-15 P.m. Child Welfare Clinic, Grange Road, Plaistow,E.13. REPORT ON THE WORK OF THE SPEECH CLINICS by Miss R.Clarke, L.C.S.T. There have been no marked changes in the work at the Speech Clinic during 1956. There have been clinics for nine sessions a week at the Greengate Speech Clinic and two sessions a week at Grange Road Maternity and Child Welfare Clinic. In addition to this there have been seven sessions at the Elizabeth Fry Spastic Unit and one session at Gurney Special School. Statistics: Number of children who attended Boys 125 Girls 44 Total: 169 118 Types of Defect Dyslalia 79 Stammer 36 Stammer with dyslalia 9 Sigmatism 16 Hyperrhinolalia 5 Cleft palate 5 Dysarthria 1 Dysphonia 1 Cerebral palsy 17 Discharged Improved 63 The children who received treatment at the Elizabeth Fry Spastic Unit numbered 23. Of these nine needed daily treatment and the rest required two or three treatments a week. It is becoming increasingly difficult under the present staffing to arrange sufficient speech therapy for these children. Similarly at Gurney Special School it has been possible to arrange for only one session a week. This means that only the more severe cases receive treatment. These children have been found to benefit from speech therapy over a period of time and we wish it could be possible for more of the children with speech difficulty in this school of which there are quite a large proportion, to have treatment. It is also well known that "little and often" is a necessary motto to adopt in work with these children. We have continued with the pre- school group, and nine children referred from the Maternity and Child Welfare Department have Joined the group during the year. It has been noticed that the majority of the children respond quickly to treatment at this age, and it is felt that this Is most probably due to the lack of an established habit factor in very young children. Once again our thanks are due to all those who have co-operated in our work. CHILD GUIDANCE. This clinic is held at the Credon Road School, Plaistow, E.13. and is open daily (Monday to Friday) from 9 a.m. to 5.15 P.m. Dr.T.P.Riordan, the Medical Director of the clinic has kindly sent the following report on the year's work. REPORT ON THE WORK OF THE WEST HAM CHILD GUIDANCE CLINIC by T.P.Riordan, M.D., B.Ch., D.P.M. The table of statistics following this report covers the main features of the work of the Child Guidance Clinic for the year 1956. 119 For most of the time the team has been without a Psychiatric Social Worker. In the absence of this essential member, the psychiatrists have delved for themselves in the social field and drawn freely on the help of the Local Health Authority Psychiatric Social Worker, Health Visitors, Officers of the Children's department, Probation Officers and officials of the Education department. While such measures have not proved an adequate substitute for the contribution of the Psychiatric Social Worker, they have had at least two interesting side effects. Firstly, the Psychiatrists have been impressed by the value of devoting more of their time to the needs of the parents and the whole family rather than to the problem of the Individual child. Secondly, co-ordination between the work of the clinic and that of other agencies engaged in the welfare of children has improved. In general, the volume of work has been maintained throughout the year and inevitably the bulk of clinical time and effort has been spent in maintaining the existing diagnostic and treatment service. The contribution which the clinic should make to the promotion of mental hygiene by regular conferences with teachers, parents and other adults in contact with children has been meagre. This aspect of the work cannot be developed until the staff is at full strength and reinforced by the services of a non-medical psychotherapist and additional sessions from Educational Psychologist. In comparison to the previous year's figures, the number of cases referred from the usual sources show some appreciable variations. The School Medical Officers, the Head Teachers and Maternity and Child Welfare Staff have referred fewer cases while Parents, Probation Officers and Education department have sent more. The meaning of these changes is difficult to assess, but the overall trend implied in them appears to be a desirable one. Certainly the evidence that parents are taking more initiative in getting advice on their family problems is encouraging although it may represent an unsustained response to the stimulation of relevant programmes at the cinema or on the radio and television. The reduction in the number of referrals from the School Medical Officers seems to coincide with a greater proportion of really difficult cases from this source and may mean more rigorous selection and screening. The spreading consciousness in Maternity and Child Welfare circles of the importance of recognising and helping to resolve emotional difficulties arising in the family setting during the child's earliest years means that problem situations are detected earlier and often at a stage when they can be resolved without reference to the Psychiatrist. Some 25# of cases seen during the year have been taken on for treatment and more Individual than group treatment has been given. As always a major stumbling block to the establishment of successful treatment is the difficulty in bringing the relevant home and school personalities effectively into the treatment situation. Even the least ambitious therapeutic plan for an individual child is likely to prove worthless if it does not take into account the child's total setting and be consistent with limiting factors inherent in attitude of parents and teachers. Direct consultation with parents or teachers readily meets resistance to psychotherapeutic advice which is often accepted on an intellectual level and rejected on an emotional plane. However, the practice of taking groups of parents together for mutual discussion of problems in the presence of the Psychiatrist who takes a non didactic psychotherapeutic role is helping to overcome this difficulty. The parents enjoy these group meetings. They gain confidence quickly and are soon whole-heartedly sharing in the treatment situation in a constructive and knowledgeable manner. This use of group therapy methods might well be extended to embrace teachers who could use the material of a case conference for exploring and sharing divers attitudes to the common emotional and educational problems of school children. 120 More than two hundred cases were closed during the year and each treated case summarised on closure. The system of regular follow-up of closed cases has continued. Because of clinical time that would otherwise be involved, most cases have been checked by letter. The response to follow-up enquiries has been satisfactory. The results are of such interest that it is hoped that it will be possible to include them in next year's table of statistics. Trainee paediatricians, trainee psychiatrists, occupational therapy students and teachers of a training course for the management of maladjusted children have visited the clinic to study methods of examination and treatment. Although these visits tend to encroach on the time already allotted to case work, they usually bring a compensatory stimulus to the life of the clinic and help to keep it equably orientated. With the initiation of a new Preventive Mental Health Training programme by West Ham Health Authority and the prospect of a full staff complement at the Child Guidance Clinic during the coming year, a comprehensive Local Authority contribution to the Mental Health Service in which the Child Guidance Clinic will take its full share can be anticipated. STATISTICAL SUMMARY OP ACTIVITY OF CHILD GUIDANCE CLINIC STAFF Consultant Psychiatrists: T.P.Riordan, M.D., D.P.M. (Medical Director) 4 sessions weekly Geo. Somerville, M.D., D.P.M. 1 session " J.E.Glancy, M.D., M.R.C.P., D.P.M. 1 " " Educational Psychologist; Mrs. E.Nathan, Dip. Psych., A.B.Ps.S. 6 sessions weekly Psychiatric Social Worker Miss Mayne, B.A. (until 29th February 1956) Secretary Mrs.Peters (Full time) Psychiatrist's interviews at Clinic 714 Psychologist's " " " 203 " testing interviews at school 54 " school visits 12 psychological tests only 26 " " retests only 26 Psychiatric Social Worker's interviews at clinic 71 " " 11 home visits 1 " " " other visits 0 Remedial coaching interviews at clinic (with Miss Marshall) 397 Number of cases newly referred 174 " " " re-opened 14 " " 11 " for retests only 26 Waiting List 30 Total number of cases dealt with 313 121 AGE INCIDENCE Under 5 years 5 to 11 years 11 years + Cases carried over 6 89 34 New referrals and 23 129 62 reopened cases SEX Male Female Cases carried over 86 43 New referrals and 131 03 reopened cases SOURCES OF REFERRAL Cases carried over School Medical Officers 57 Head Teachers 23 Maternity & Child Welfare Department - General Practitioners 10 Children's Department 8 Education Department 6 Parents 10 Probation Officers 4 Hospitals 5 Others 6 New referrals and re-opened cases School Medical Officers 86 Head Teachers 27 Maternity & Child Welfare Department 15 General Practitioners 9 Children's Department 8 Education Department 23 Parents 22 Probation Officers 9 Hospitals 9 Others 6 Intellectual level of cases tested including those referred for ascertainment only Cases carried over New referrals and re-opened cases Above 11 Above 20 Average 60 Average 55 Below 21 Below 15 E. S. S. 7 E.S.N. 45 Treatment Cases carried over New referrals and re-opened cases Individual 32 Individual 20 Group 11 Group 12 Both 7 Both - Remedial coaching 12 Remedial coaching 8 122 DISPOSAL Cases carried, over from previous year Still under treatment 37 Closed 92 Improved 29 Not Improved 2 Before end of treatment (Improved) 8 " " " " (not improved) 15 Never attended 9 Diagnosis only 17 Psychological test only 8 Retests only 4 Court reports 2 Placement recommended 10 (Fyfield 4 (E S. N. school l (School for maladjusted 4 (Spastic Unit 1 Cases newly referred and re-opened Still open 91 Under treatment 39 Partially Investigated 11 Awaiting treatment 11 Waiting List 30 Closed 123 Improved 8 Before end of treatment (improved) 3 " " " '' (not improved) 2 Never attended 18 Diagnosis only 23 Psychological test only 43 Retests only 26 Court reports 10 Placement recommended 12 (E.S.N, school 8 (Occupation Centre 3 (School for maladjusted 1 123 HANCICAPPED CHILDREN CATEGORIES OF HANDICAPPED PUPILS: SPECIAL EDUCATIONAL TREATMENT The several categories of handicapped pupils requiring special educational treatment were re-defined by revised Regulations made during the year 1953. The definitions are quoted In the various sections dealing with the particular handicap. The early ascertainment of handicapped pupils is one of the most important functions of the School Health Service. The Education Authority Is responsible for the ascertainment of all handicapped children over the age of two years who require special educational treatment. As a general principle, handicapped children attend ordinary schools provided they are able to profit by the education offered, and that they do not disturb other children by their presence. Children are not removed from their homes to residential Institutions unless it is considered they will clearly benefit from the transfer, or unless their presence in a day school is prejudicial to other children, Previously, epileptic and physically handicapped pupils were so defined as to imply that they could not be educated in an ordinary school. In fact, many of these children can be educated in ordinary schools if special arrangements are made or facilities provided to enable them to overcome their particular disabilities. As few children are "ascertained" as physically handicapped there continues to be vacancies at the Elizabeth Fry Special School. Children who stammer or who have other speech defects are given treatment - usually once or twice a week - at the speech clinic to which they go while attending ordinary schools. In addition, the day special schools for educationally sub-normal and physically handicapped children are visited by the speech therapists so that any children needing treatment may have It. The usual treatment given at the speech clinics is not regarded as special educational treatment. Advice on improvement of the arrangements for the special educational treatment of ^physically handicapped children was given in Circular 300, issued on 23rd March, 1956. The attention of local education authorities was specially drawn to the need for ensuring that "regular and sufficient" physiotherapy and speech therapy are available for all physically handicapped children who require these forms of treatment. Details regarding the categories of handicapped pupils requiring special educational treatment are contained in the "School Health Service and Handicapped Pupils Regulations, 1953", as follows:- BLIND AND PARTIALLY SIGHTED CHILDREN. A blind pupil is defined as one who has no sight, or whose sight Is or is likely to become so defective that It requires education by methods not involving the use of sight. Blind pupils must be educated at a special school unless the Minister determines otherwise. A partially sighted pupil is one who, by reason of defective vision cannot follow the normal regime of an ordinary school without detriment to its educational development, but can be educated by special methods involving the use of feight. In classing a child as partially sighted both ophthalmic standards and educational needs are taken into account. 124 ASCERTAINMENT OF BLIND AND PARTIALLY-SIGHTED PUPILS. This subject was dealt with in the last report, but it can with advantage be considered again. The medical examination for the ascertainment of blind and partially sighted pupils is carried out by a medical officer of the Authority in the same way as for any other category of handicap. As a preliminary step the recommendation of an ophthalmic specialist must be obtained, the specialist completing at the same time the revised Form B.D.8. Form B.D.8 used for blind and partially sighted pupils, was revised in March 1955 and the Minister of Education in his Administrative Memorandum No.493 dated 2nd March 1955, hoped that local education authorities would normally ensure that a report on this revised Form by an ophthalmologist of consultant standing is available to them when they are considering the provision of special educational treatment for any pupil whose eyesight is thought to be defective. The former "certificate" in Form B.D.8 has been supplemented by a "recommendation" as to the educational needs of a child under 16 years of age. Completion of the "certificate" on the back of Form B.D.8 is appropriate when the ophthalmic consultant Is concerned with placing the child on the register of blind persons or on the register of partially sighted persons, whilst in completing the "Recommendation in Respect of a Child", he is acting in another capacity in that he is advising the local education authority whether a child should be considered a blind pupil or a partially sighted pupil within the meaning of the School Health Service and Handicapped Pupils Regulations, 1953. In practice it is found convenient to combine the medical examination required for admission to the blind or partially sighted register with that required for ascertainment as a handicapped pupil under Section 34 of the Education Act, 1944. The decision to admit a blind or a partially sighted child to a special school is an educational one which has to be taken by a local education authority after full consideration of all the information available, and although the importance of the ophthalmic findings cannot be ignored, due weight must be given to various other factors. Also, when a child has been admitted to a special school for partially sighted pupils, his ophthalmic and educational progress should be kept under continual review because, if this is done, it has sometimes been found possible to return some of these children to ordinary schools. The definition of partial sight was dealt with in Appendix IV to Circular 4/55 when the ophthalmological standards were given as follows:- " for children whose visual acuity will have a bearing on the appropriate methods of education - (a) severe visual disabilities - to be educated in special schools by methods involving vision - 3/60 to 6/24 with glasses; (b) visual impairment - to be educated at ordinary schools by special consideration better than 6/24 with glasses." In the Health of the School Child for the years 1952-53, guidance was given on the selection of children for schools for the blind or for the partially-sighted, and in the case of partially-sighted children it was stated that the range of visual acuity should be from 6/24 to 6/60 In the better eye. It will be seen that the range for partially sighted pupils has now been slightly extended at the expense of the blind range, i.e., 6/24 to 3/60 with glasses. 125 When the Form B.D.8 is received by the School Health Service two copies are made. One of the copies is retained in the School Health Service and inserted in the child's dossier; the original and the other copy is passed to the Chief Welfare Officer. This document is sent to the Chief Welfare Officer irrespective of whether or not the child is considered to be a handicapped pupil and irrespective of whether or not it is considered likely that the child would qualify for inclusion in the Blind Register after leaving school. If the ophthalmologist's opinion indicates that the child is likely to be ascertained as blind or partially sighted the normal procedure under Section 34 of the Education Act, 1944, is put into operation. In addition to the revised Form B.D.8 the Local Education Authority have before them advice from the School Medical Officer and information from teachers and others who have known the child, and will consider his age, attainments and intelligence and qualities of character which may influence his suitability for one school or another. The Authority has no schools of its own for the education of blind and partially sighted pupils owing to insufficient numbers, but where possible arrangements are made for these children to be admitted to day or residential schools conducted under other auspices. Nursery education up to the age of six or seven years is provided mainly by the Sunshine Home Schools which are managed by the Royal National Institute for the Blind. At the age of six or seven children are transferred to schools for the blind. The instruction for boys includes woodwork, basket work and modelling; for girls, housecraft, knitting, light basketry and simple sewing. Reading and writing are taught through the medium of Braille, arithmetic by a system of arranging types in a board, and geography by means of embossed maps. Typewriting is also taught at a later age. Certain pupils can continue their training beyond the age of sixteen and, in addition to typewriting, take up shorthand or telephony, pianoforte tuning, basket weaving or machine knitting. In the case of partially sighted children the curriculum resembles that in schools for children with normal sight. Written work is done by using chalk on blackboards or with thick crayon on large sheets of paper. Reading books with large type are used by the junior children and a special reading lens on a stand is supplied for every pupil of secondary school age. The following figures relate to work carried out in connection with blind and partially sighted children during the year:- BLIND Number ascertained during the year 3 Number in Residential Special Schools during the year 2 Out of School 2 In Day Special School for Partially Sighted Pupils 1 (On waiting list for Condover Hall) PARTIALLY SIGHTED Number known to the Authority during the year 10 Number ascertained during the year 1 Position at the end of the year: In Day Special Schools 9 In Residential Special School 1 Out of School Nil 126 The incidence of partial sightedness for special educational provision remains fairly constant at 0.33 per 1,000 registered pupils. There is close liaison between the Chief Assistant School Medical Officer and the Ophthalmologist on this subject. DEAF AND PARTIALLY DEAF PUPILS. A deaf child is defined as one who has no hearing or whose hearing is so defective that it requires education by methods used for deaf children without naturally acquired speech or language. A deaf child must be educated at a special school unless the Minister determines otherwise. In all the schools for the deaf the oral system of speech and lip reading is used. Those children who have enough hearing make full use of group hearing-aid apparatus in specially equipped classrooms and are supplied with individual hearing-aids for personal use. The normal curriculum is followed as far as possible but with particular stress on lip reading and language development. Some of our children with the highest academic ability go at the age of twelve to a voluntary special school, The Mary Hare Grammar School for the Deaf, Newbury, which is the only one of its kind in the country. A partially deaf child is one who has some naturally acquired speech and language but whose hearing is so defective that it requires for its education special arrangements or facilities though not necessarily all the educational methods used for deaf children. This includes lip reading and training in the use of individual hearing-aids. Occasionally some of these partially deaf pupils return to ordinary schools and are able to work with other children, provided they are placed in a favourable position in the classroom and continue to use hearing-aids. Lip reading is the art of reading correctly the speech of others from observation of the movements of the mouth, face and throat. The ability to lip-read varies greatly. Quite a number of children with defective hearing seem to acquire the skill unconsciously, without having had any lessons, so that a severe degree of deafness can exist in such children and remain for a long time unsuspected. They are natural lip-readers. Most children learn to lip-read fairly readily, although one cannot say beforehand whether the child will learn to lip-read quickly or slowly. Some children find it difficult however hard they try although they may be quite intelligent. Tuition in lip-reading is usually given by teachers of the deaf. One child attended the School for the Deaf weekly for auditory training. The emphasis nowadays is on the need for early ascertainment of deafness in young children, so that auditory training can be commenced at a time when the residual hearing possessed by the majority of deaf children can be used to its full extent. Figures relating to work carried out in connection with deaf and partially deaf children during the year are set out below:- Number ascertained during the year: Deaf 2 Partially deaf 1 Disposal of ascertained cases: Admitted to day special school (deaf) 1 Admitted to residential special school (deaf) 1 Admitted to day special school (partially deaf) 1 Number known to the Authority at the end of the year: In residential special schools (deaf) 6 In day special school (deaf) 21 In day special school (partially deaf) 8 127 EDUCATIONALLY SUB-NORMAL CHILDREN. These children are defined as pupils who, by reason of limited ability or other conditions resulting in educational retardation, require some specialised form of education, wholly or partly in substitution for the education normally given in ordinary schools. Children who possess limited intelligence and in consequence become retarded may make little progress in ordinary schools. The following figures relate to work carried out in connection with educationally sub-normal children during the year:- Number ascertained during the year 20 Disposal of ascertained cases: In ordinary schools Nil Recommended day special school 19 Recommended residential special school 1 Number of cases known to the Authority at the end of the year: In ordinary schools 72 In day special schools 149 In residential special schools 12 Fresh admissions to special schools during the year: In day special school 22 In residential special schools 2 EPILEPTIC CHILDREN. The definition of an epileptic child for our purpose is one who, by reason of epilepsy, cannot be educated under the normal regime of an ordinary school without detriment to himself or other pupils. There are many epileptics whose disability is not so severe as to be incompatible with a normal school life, and it is in their best interests that they should be educated at an ordinary school. The more closely a child can live like his fellows the more likely he is to grow up mentally balanced with a normal healthy outlook. Many children with the less serious forms of epilepsy can be educated at ordinary schools if facilities are provided to enable them to overcome their particular difficulties. It is only when an epileptic is clearly unable to fit into an ordinary school and life that he should be "ascertained" and the rather drastic step taken of arranging special education for him. Fortunately this is rarely necessary as will be seen from the figures given later. The total number of children known to have epilepsy is about 2 per 1,000 registered pupils. All children known to be epileptic are followed up to see that they receive regular treatment from their family doctor or from a hospital out-patient department. Although the dally life of the epileptic child should be interfered with as little as possible he should not, of course, be allowed to go swimming or climbing trees and ladders, and when he becomes an adolescent he must not be permitted to drive a car, but all restrictions should be kept to a minimum. Encouragement and hope are fundamental requirements in the management of an epileptic. Parents are advised not to fuss the child, and not to over-protect him from the ordinary rough and tumble of childhood. The general welfare of epileptic school children is a concern of the school medical officers who have opportunities for observing their cases and reporting on various aspects of the problem of epilepsy, e.g., the results of the latest methods of treatment. 128 When epileptic children do require special education treatment at a special school the Authority places them in the care of voluntary organisations who manage special establishments for epileptic children. Occasionally such a child is placed in the day special school for physically handicapped pupils. The number of non-ascertained cases known to the Authority is 53. Data relating to ascertained cases of epilepsy during the year may be summarised as follows:- Number of ascertained cases known to the Authority 5 Number of cases in residential special schools k In day special school 1 Number of fresh ascertainments during the year 1 PHYSICALLY HANDICAPPED CHILDREN. Physically handicapped pupils are pupils not suffering solely from a defect of sight or hearing, who by reason of disease or crippling defect cannot, without detriment to their health or educational development, be satisfactorily educated under the normal regime of ordinary schools. The purpose of a school for physically handicapped children is to provide an environment appropriate to their special needs; an environment where their particular disabilition may receive proper and continuous care while their education continues.. The curriculum includes opportunity for practical work and a full range of general and cultural subjects, special equipment, furniture and apparatus are supplied to meet the needs of individual children; physiotherapy and speech therapy are available for all those requiring these forms of treatment. Fortunately, a number of children Improve so much in health and In ability to conquer their handicap that they are able to be transferred to ordinary schools. Six children were transferred to ordinary schools during the year. The Authority maintains a day special school for physically handicapped pupils. The following figures set out the position regarding physically handicapped children in the Borough during the year 1956:- Total number known to the Authority (includes all children on register at any time during the year): Heart cases 8 Cripples 57 Miscellaneous 12 Physically handicapped children in residential special schools (including hospital schools so far as information is available): Heart cases 1 Cripples 1 Miscellaneous 1 Physically handicapped children in day special school: Heart cases 6 Cripples 56 Miscellaneous 11 Out of school cases: Heart case (since deceased) 1 Fresh ascertainments during the year: Heart cases 1 Cripples 3 Miscellaneous 1 129 DELICATE CHILDREN. These are children not falling under any other category of the School Health Service and Handicapped Pupils Regulations, 1953, who by reason of impaired physical condition, need a change of environment or cannot, without risk to their health or educational development, be educated under the normal regime of ordinary schools. Since 1925 most of our delicate children were sent to the West Ham Residential Open Air School, Fyfield; some were sent, and still are, to convalescent homes approved by the Ministry of Education for long-term cases. The usual types of children sent are those suffering from asthma, bronchitis, debility, poor physical condition, anaemia and chronic catarrh. In view of the improved condition of the children it was becoming more and more difficult to find a sufficient number of children to keep the school anywhere near full. Consequently the West Ham Residential Open Air School was closed on 7th September, 1956. Children with chronic pulmonary conditions, such as "chronic bronchitis", asthma, bronchiectasis, have always presented a baffling problem to school medical officers. Such children are most inconstant attendants at school and are frequent at the clinics. Children with mild or infrequent attacks of asthma, which do not seriously effect their school attendances, and whose physical condition is satisfactory, may very well be left in the ordinary school. But there are cases where life in the open air school does benefit the asthma sufferer's health, and at the same time enable him to get more education than he otherwise would. There is no doubt that it is a beneficial procedure In certain cases to send them to open air schools. Asthma children are usually quite bright and intelligent and, in view of their physical handicap,should get as good an education as possible. These cases usually require a long stay in the open air schools and this is the chief type of case for which we shall have to make provision. Since the closing of Fyfield more use has been made of other residential open air schools and convalescent homes providing schooling. Figures relating to admissions to Fyfield and to convalescent homes during the year will be found on pages 135-136 and 138-139. The number of children "ascertained" as delicate during the year was 42, and their disposal was as follows:- Admitted to West Ham Residential Open Air School 37 Admitted to other residential open air schools 3 Refused to go away 2 130 MALADJUSTED CHILDREN. These are children who show evidence of emotional instability or psychological disturbance, and require special educational treatment in order to effect their personal, social or educational readjustment. Some children of normal intelligence find difficulty in making good relationships with adults or other children either at home or at school. They are often retarded in school subjects and sometimes delinquent. Such children are first investigated at the Child Guidance Clinic and the diagnosis established. The special educational treatment required is advised by the clinic and often wholly or partly carried out there. A few acutely maladjusted children need a period away from home and in these cases the Authority make arrangements with voluntary organisations managing special schools or with independent boarding schools. The School Health Service has established itself firmly as an essential and unique service in the field of preventive medicine. Towards the end of 1955 the Report of the Committee on Maladjusted Children was published. The report emphasised the fundamental importance of the prevention of maladjustment in children, not only by its early detection, but also by guiding aright all children in their emotional development and so preventing maladjustment from arising or developing. The School Health Service with its teachers, educational psychologist and other skilled workers, has an important part to play in the implementation of the Committee's recommendations. Great importance is attached to the promotion of good mental health and to the prevention of maladjustment. Health visitors and school nurses held positions of great possibility in the sphere of prevention by virtue of their work with the school doctors, their visits to the schools, and most important, to the home. The Committee recognised their value, and recommended an extension of their functions and an adaptation of their training, so as to make them more effective in this field. It is Interesting to note that the Committee of Inquiry on Health Visiting, set up jointly by the Minister of Health, the Minister of Education and the Secretary of State for Scotland, supported their valuable use in this way. Stress was laid on the "early years" as they are of such great importance. Joint appointments have obvious advantages and provide opportunities for the prevention of maladjustment during the formative early years of childhood. Intimate co-operation between the School Health Service, the Maternity and Child Welfare Service and other health services of the local authority is most valuable and joint appointments such as school nurse/health visitor, and school medical officer/maternity and child welfare officer should be encouraged. The number of children "ascertained" as maladjusted during the year was 2; they were both recommended for admission to a residential school. PUPILS SUFFERING FROM SPEECH DEFECTS. These are pupils who, on account of defect or lack of speech not due to deafness require special educational treatment. Children suffering from disturbances of speech need only be formally ascertained as handicapped pupils if the disability is so great that they need special educational treatment, i.e.,'some modification of the educational regime as distinct from.medical treatment. No children were ascertained under this category during the year. Children who stammer or who have other defects of speech are given special treatment at the speech clinics to which they go while attending ordinary schools. The day special schools for physically handicapped and educationally sub-normal Pupils are also visited by the speech therapists so that any children needing the specialised treatment may have it. An account of the work at the speech clinics appears on pages 117 to 119. 131 CHILDREN WITH MULTIPLE DEFECTS. Children handicapped by more than one defect often present a serious problem in arranging suitable education, as there are so few schools which specialise in the education of children with dual disabilities. There is need for further provision which can only be made on a national basis, since no authority is likely to have more than three or four children with any particular combination of disabilities. In the year 1956, four cases were known to the Authority. The particulars are as follows At Elizabeth Fry Special School 1 girl, aged 15 years Physically handicapped (alopecia) and educationally sub-normal. 1 girl, aged 10 years Physically handicapped and educationally sub-normal. 1 girl, aged 13 years Physically handicapped and partially sighted. At Ryder Special School 1 girl, aged 13 years Blind and educationally sub-normal (waiting admission to Gondover Hall) EDUCATION SERVICES Close liaison with many of the education services is essential in the interests of the health and well-being of the pupils. Among those which present special considerations relating to physical or mental health are the nursery and sp.ecial schools, the youth employment bureau and also the remedial classes for backward children which come within the scope of the school psychological service. All these are the responsibility of the Chief Education Officer to whom I am indebted for much of the material in these sections of the report. A, school psychological service has been provided for some time by the local education authority. The part which such a service can play in preventing maladjustment from arising or worsening Is great. It is chiefly in the schools that early deviations from normal emotional development are seen, and it is there that skilled observers should recognise them as soon as they appear and deal with them if they fall within the field of education or psychology. Many emotional problems which arise in childhood have their roots in educational strain, and they can be solved by wise handling and adjustment within the educational system. The local education authority look to the educational psychologist for advice on many educational problems, both general and particular. Teachers will seek her help on their perplexities regarding the behaviour or learning difficulties of individual pupils. For the school psychological service to be effective all groups of workers - school medical officers, teachers, school nurses - all experts in their respective ways - have to be taken into account. Between them they know a great deal about the handicaps, schooling, physical and emotional progress, background and home conditions. If the child is felt to have an emotional disturbance which cannot satisfactorily be dealt with in the school, the educational psychologist will refer the child to the child guidance clinic for full investigation by the team established there. It is essential that the psychologist be a member of the child guidance team. 132 SPECIAL SCHOOLS The Authority is responsible for the following special schools: Name of School purpose for which Used Gurney Educationally sub-normal Elizabeth Fry Physically Handicapped West Ham School for the Deaf Deaf and partially deaf West Ham Open Air School Delicate children (to 7th September, 1956) GURNEY SPECIAL SCHOOL This school caters entirely for educationally sub-normal pupils of all ages. The capacity of the school is 160. The maximum number on the roll during the year was 149. During the year 22 children were admitted by reason of educational retardation and 24 left. The leavers were dealt with as follows:- Fourteen left at 16 years No action Six were notified to the local authority as requiring supervision after leaving school. One admitted to residential school. Three removed from the district. ELIZABETH FRY SPECIAL SCHOOL This school caters entirely for physically handicapped pupils of all ages. At the end of the year a communication was received by the Chief Education Officer from the Ministry, of Education setting out the following revised accommodation figures for this school - all age pupils 95; spastic unit 12. The maximum number on the roll during the year was 86 of whom 25 were extra-district children. During the year 17 children were admitted to the school on account of a physical handicap, including 10 extra-district children; 18 West Ham children and 3 extra-district children left the school. The West Ham leavers were disposed of as follows:- Notified to local authority Section 57(3) 1 Returned to ordinary school 6 Allowed to leave school at 15 years 2 Left school at 16 years and reported to the Youth Employment Officer as Disabled Juveniles 4 To residential school 1 Left the district 3 Unfit for school 1 133 An analysis of the causation of defect in 73 West Ham cases and 28 extra-district cases which were in the school during the year 1956 is set out below:- Defect West Ham Extra-District Heart conditions (congenital and rheumatic) 6 3 Paralysis 15 4 Spastic conditions 15 16 Quiescent T.B. bones and joints 5 - Muscular dystrophy 3 - Perthe's disease 4 - Fragilitas ossium 2 - Miscellaneous conditions 23 5 73 28 The miscellaneous conditions Include such cases as myositis ossificans, severe congenital scoliosis, Hand- Schuller Christian disease, achondroplasia, post- vacclnal encephalitis, ectopiae vesicae, arthrogryposis, cerebellar tumours, congenital absence of bones, amputations, post-operative rupture of liver and other defects. The Ministry of Education favour the retention of handicapped pupils in ordinary schools whenever possible and this is followed in practice. During the past twenty years or so there have been very great changes in the Incidence of some of the diseases which cripple children. The number of children with serious orthopaedic defects, especially those with tuberculosis of bones and joints, continues to decline: the latter condition stood high in the list of causes; now it is well down and it is hoped, will ultimately disappear. Rheumatic heart disease affects fewer children than it did even a few years ago, and there are now In the special school more children disabled by congenital heart defects than by rhfeumatlsm. There is every promise that poliomyelitis will be prevented by vaccination. Then the remaining cases in the special school will be mostly congenital defects - cerebral palsy, defects of the heart, fragilitas ossium, and haemophilia. At the moment we have no cases of haemophilia, although a short time ago we had as many as four. The incidence of physically handicapped pupils in the day special school is in the region of 2 per 1,000 registered pupils. ELIZABETH FRY SPASTIC UNIT This Unit, attached to the Elizabeth Fry Special School was opened in June, 1954 The Unit is under the control of the head teacher of the parent school and Is a specially designed single-storey building. A full account of the Unit appeared in the report for 1954 The procedure for the admission and the attendance of pupils was also described at the same time. In addition to the children in the nursery class of the Unit a large number of pupils from the parent school attended for treatment In the large appropriately equipped physiotherapy treatment room and also in the speech section. The progress of the children has been very satisfactory. The Unit continues to arouse much Interest, not only locally, but over a wide area and many visitors, both individual and in groups, visit it In order to observe its workingBy the end of the year 13 children under the age of seven years were in the Unit. Of these 13 cases ^ were extra-district. In addition 4 cases attended the Unit on an out-patient basis, 1 under two years of age. Of these 4 two were extra-district. Of the 13 children in the Unit all were receiving physiotherapy and 8 speech therapy. 134 WEST HAM SCHOOL FOR THE DEAF The capacity of this school, which also takes children from East Ham and contiguous areas of Essex is 120 and the maximum number of children on the roll during the year was 83, including 59 extra-district children. Of the 93 children in attendance during the year, 22 West Ham cases and 51 extra-district cases were regarded as deaf and 7 West Ham cases and 13 extra-district cases as partially deaf and suited for instruction with hearing aids. The admissions to and discharges from the school are set out below:- Admissions West Ham Extra-district Deaf 2 5 Essex Partially deaf 1 Nil Leavers Deaf 1 4 Essex 1 East Ham Partially deaf Nil 2 Essex 1 East Ham The extensive audiometric surveys have confirmed a number of children with hearing loss. The defect is known to parent and teacher, and can be relieved or improved by medical treatment, favourable position in class, and in some cases provision of a hearing aid. It is only rarely that the parent or teacher discovers a partially deaf child for whom special educational treatment in a special school is necessary. Late-deafened pupils, that is, children who had become deaf after they had acquired speech and language, fall into the partially deaf category. The speech of a child deafened as a result of meningitis will deteriorate or be lost, however many years of speech he had known prior to his Illness, unless early and energetic steps are taken to avert the decline. WEST HAM RESIDENTIAL OPEN AIR SCHOOL. FYFIELD. During the year 47 West Ham boys and 17 West Ham girls were admitted and 75 West Ham boys and 39 West Ham girls were discharged. Of extra-district children 13 boys and 3 girls were admitted and 29 boys and 7 girls were discharged. The West Ham children are reinspected by the area medical officers a few months after they leave the school to ascertain if their improvement has been maintained. Of the 96 who attended for examination 87 showed continued improvement, but 9 children had not maintained their condition. During the year the Chief Assistant School Medical Officer made five visits to the school for the purpose of reinspecting the pupils and carrying out Immunisations. 135 In the Annual Report for 1955 It was stated that it had become increasingly difficult to "ascertain" as delicate a sufficient number of pupils to maintain the school at its full complement; this particularly applied to the girls. The physical condition of the pupils continues to improve. It is most significant that of suspected cases of malnutrition referred to the paediatrician no frank cases have been confirmed since 1949. In his report for this year Dr.Hinden states, "it is rare nowadays to see a child who is suffering from malnutrition". The provision of milk and meals in schools, a slow but gradually improving housing position, and a rising standard of living all help to improve the health of the child. Our new schools can offer facilities similar to those found in open-air schools and there may not be much physical advantage in a transfer. A paragraph in my last report, "Bearing these points in mind and with a fuller appreciation in the ordinary schools of the varying needs of individual children, the time is coming when there will be little need for open-air schools for 'delicate' children," has a bearing on what happened to Fyfield this year. The school was closed on 7th September because it was not possible to "ascertain" as delicate a sufficient number of pupils to maintain the school at anything like its full complement. It will always be necessary to send a certain number of children to residential openair schools: these will be some of the asthma, "chronic bronchitis", and bronchiectasis cases. Selected cases of asthma, under the regime of open-air schooling, which includes special breathing exercises, do well in the main. They have always presented a problem to the school health service. Now that Fyfield is closed more use will be made of extended convalescence. Fyfield was in existence over 30 years and it fulfilled Its purpose. NURSERY SCHOOLS The authority has four nursery schools, two, the Edith Kerrison and the Rebecca Cheetham, of long duration; and two, Osborne Road and Station Street previously day nurseries, of short duration. The schools are visited quarterly by the medical officers for the purpose of examining the children. The first examination of the child is classed as an "Entrant" Inspection; other examinations during the same year as reinspections. The first inspection in any calendar year other than in their first year is classed as "Additional Periodic Inspection"; other examinations during that year as reinspections. The results of Inspection during the year are set out below:- Number examined Number found to Percentage found to require treatment require treatment 820 27 3.29 When the children were examined for the first time during the year, their physical condition, using the Ministry of Education new classification, was as follows:- Number examined Satisfactory Percentage Unsatisfactory Percentage 403 402 99.75 1 0.25 136 The defects which are most frequently found at the medical inspections are bronchitis and upper respiratory catarrh, nose and throat conditions, and minor orthopaedic defects. The great importance of medical supervision of nursery schools lies in the opportunity to detect the earliest beginnings of disease at a stage when remedial measures are comparatively easy to apply and may prevent the development of more serious trouble. Nursery Schools do not give formal instruction but produce a condition of readiness for such instruction later, and so prepare the children for the infants' school. The aim of nursery school training is to foster by means of carefully planned methods the fullest possible development of a child in body, mind and spirit between the ages of two and five years. The carefully balanced diet at the midday meal, the afternoon rest, the regular medical inspections and the frequent visits to the school of a nurse who promptly reports any abnormality, all contribute to the physical and mental well-being of the children. Playrooms are as light and airy as possible, and whenever weather permits most activities take place outside in the open air. Special attention is paid to hygiene; each child has his own comb, face flannel and towel; high standards of personal cleanliness are set. The nursery school is to some extent an observation centre, both medically and socially, where the progress of health and development of character can be carefully watched and guided in the child's best interests. Experience has shown that fears lest the removal of these young children from the home would result in lessened parental responsibility have little foundation. On all sides evidence is forthcoming that increased parental Interest, responsibility and co-operation for the welfare of the child are obtained. This is shown in Increased cleanliness and nurture, both personal and domestic, a wiser dietary and in many cases more suitable clothing. The nursery school trains the child in good personal and social habits, and it exerts an influence for good on the standards and ideals of the home. The nursery school frees the mother without usurping her place. The nursery school environment greatly assists serenity of development, and saves the child much of the strain which is inevitable in the ordinary home where the needs of the elders constitute the central pivot of organisation and the little one has to be fitted in as well as possible. Facilities are given to the medical officers to visit the schools from time to time to observe the environmental conditions and to make a critical assessment of their value in promoting health. In can truly be said that a well planned and well run nursery school with good open air life, plenty of space, adequate clothing for their "in-and-out" life, and a really high standard of feeding, will ensure the well-being of the children, increase their resistance to disease and reduce the risk of infection. Miss Grace Owen, one of the pioneers of the nursepy school movement, summed up the aims of the nursery school many years ago as - 1. To provide healthy external conditions for the children- light, sunshine, space and fresh air. 2. To ensure a healthy, happy, regular life for the children as well as continuous medical supervision. 3. To assist each child to form for himself wholesome personal habits. To give opportunity for the exercise of the imagination and the development of many interests as well as skill of various kinds. 5. To give experience of community life on a small scale, where the children of similar, as well as varying ages work and play with one another day by day. 6. To achieve a real unity with the life of the home. 137 NURSERY CLASSES After a period in which nursery classes were closed down three reopened for the Autumn term in 1955- New City, Carpenters and Tollgate, These classes continued throughout the year 1956. Children under five are educated in these classes in primary schools. The classes are run on the same lines as nursery schools but must not admit any children below the age of three. It has been found that children from two to five years of age develop best in small communities which have some of the features of a good home, which provide a simple life where the children can find security and satisfaction, and where there are opportunities for caring for the children as individuals. Our aim is to provide an environment and regime which will be Instrumental in raising the condition of these young children nearer the optimum and in reducing to a minimum the risks Involved in bringing them together into groups. The children are offered a variety of occupations to satisfy their needs and to develop the skilful use of their hands. Wood and bricks, hammers and nails, painting and modelling materials, jigsaw puzzles, water and sand are in general use. Children are encouraged to talk and their knowledge of words 1b increased by means of stories, songs and rhymes. They obtain their first introduction to music through movement and musical games; while in the playground or garden there is apparatus for developing the physical skills such as climbing, jumping and balancing. The children obtain as much pleasure and value out of home made things - trucks, carts, tubs and old tyres, as costly apparatus. The findings at nursery classes are, as would be expected, similar to those in the nursery schools. CONVALESCENT TREATMENT Children are sent away mainly through the Invalid Children's Aid Association; sometimes a child is dealt with by the Jewish Board of Guardians. Children are also sent away for holidays in the summer to private homes through the Children's Country Holiday Fund. These cases, however, do not come within the convalescent scheme. Most of the children sent to convalescent homes usually require short-term treatment - generally a stay of three weeks. These children are generally below par and are classed as debilitated and needing a change of environment, Some however, have had a recent illness such as influenza, bronchitis, pneumonia, measles, or are troubled with attacks of upper respiratory catarrh, and are often recommended by their family doctors for a change of air. Should a child be so debilitated as to require a longer stay than six weeks, then it must be admitted to a convalescent home providing educational facilities. Many of the children admitted to Fyfield in the past come under this category and now that Fyfield is closed it is envisaged that there will be an increase in long-term convalescent cases. 138 The mothers take a great deal of interest in these convalescent cases and when invited to bring their children to the clinics for purposes of reinspection attend in good numbers. The results from even a short stay are generally very satisfactory and at reinspection the improvement has, in most cases, been maintained. The administrative arrangements have been in the hands of the West Ham branch of the Invalid Children's Aid Association for some years, and have this year again been carried out in a most efficient manner. The personal interest shown by the staff, backed by their experience of such cases, has been much appreciated. During the year 106 children were sent to convalescent homes in the way described. EMPLOYMENT OP CHILDREN AND YOUNG PERSONS The law relating to the employment of children may be briefly summarised. The Seventh Report of the Home Office on the Work of the Children's Department, published in November, 1955 stated that, "The main statutory provisions are contained in Part II of the Children and Young Persons Act, 1933, as amended by the Education Acts, 1944—48. Section 18 of the Act restricts the employment of children who are not over compulsory school age and, in general, prohibits their employment if they are more than two years below that age. The general restrictions contained in Section 18 (1) may be modified by bye-laws which, subject to confirmation by the Secretary of State, local education authorities have power to make under Section 18 (2). Bye-laws may impose restrictions additional to those specified in the Act as to the age below which children may not be employed in the authority's area, and the hours and conditions of employment of children, and may prohibit their employment in any specified occupation." The present bye-laws regulating the employment of children outside school hours were adopted by the Council in 1949. These bye-laws made under the Children and Young Person's Act, 1933, replaced the bye-laws made by the Council in 1934. Important alterations were:- (a) No child under the age of 14 years shall be employed. (b) No child shall be employed on any week-day except from 7 a.m. to 8 a.m. provided that the employment during this hour is restricted to the delivery of milk, bread or newspapers. Other features of the Regulations are that Sunday is prescribed as a whole holiday and no child shall be employed on that day. No child taking part in any entertainment in pursuance of a licence under Section 22 of the Children and Young Persons's Act, 1933, shall be employed on the day or days of, or on the day following, such entertainment in any other employment. No child shall be employed in any work out of doors unless he is suitably shod and is suitably shod and Is suitably clad for protection against the weather. 139 Furthermore, under Section 18 of the Act mentioned, no child shall be employed to lift, carry, or move anything so heavy as likely to cause injury to him. Employment of children in West Ham is restricted to the delivery of newspapers, milk or bread. Occasionally a girl is examined in connection with paper delivery. The medical officer carrying out the examination gives a certificate on the condition of the child at the time of the examination and it is to the effect that the employment will not be prejudicial to the health or physical development of the child and will not render him unfit to obtain proper benefit from his education. In practice children from all types of school -grammar, technical, modern and special (educationally sub-normal) are examined in this way. In the case of the special school child it is the higher grade child who is presented for examination. In practice over the years it is found that there are ordinarily very few children indeed who are fit to go to school but are not fit to undertake the one hour's employment on schooldays which is allowed by the byelaws of the Council. It is very rarely that a child is found unfit. Some people regard the part-time employment of children as undesirable on medical grounds. Some years ago a Home Office Committee, in the course of an enquiry into the hours of employment of young persons, sought the opinion of the British Medical Association. In order to advise it, the Association set up a Committee, which reported that, "The evidence before the Committee does not suggest that part-time employment is injurious to the health or prejudicial to the education of young persons except in the case of grammar schools .... where it may interfere seriously with school work and, therefore, should be prohibited. Part-time employment may even be beneficial in that it encourages a sense of responsibility and healthy independence." The number submitted for examination since 1949 has progressively declined, the number in that year being 229, and for 1956, 64. The number of certificates granted for girls to participate in singing and dancing under the Entertainments Rules remained fairly constant up to 1955, when the number was 52. This year the number dropped to 16. Regarding the employment of children in theatrical work, the Committee already mentioned reported that, "Although all express some doubts about the desirability at times, none recalled any ill effects." THE SCHOOL LEAVER AND EMPLOYMENT UNSUITABILITY FOR CERTAIN OCCUPATIONS The School Health and the Youth Employment Service work closely together during the last two years of the child's school life and one of the last duties which the former service does for the child on leaving school is to give the Youth Employment Officer an indication of the child's fitness for employment. The school medical officer, at the last inspection of the child at 14 plus, makes out a general school-leaving report indicating appropriate unsuitabilities for employment. 140 There has never been any real difference of opinion regarding the desirability of using the findings of school medical officers as an aid to helping a boy or girl leaving school to find the employment for which he or she is best suited, but there have been differences of opinion regarding the way in which this could best be done. Sir George Newman, writing in The Health of the School Child for the year 1933 gave certain advice which was considered by the National Advisory Council for Juvenile Employment, which then expressed the hope that the Board of Education would bring it to the notice of local education authorities and their medical advisers. In 1935 the Board issued an Administrative Memorandum saying "The Board agree with the opinion expressed in their Chief Medical Officer's Report that the most useful form of advice is in terms related to the specific unsuitability of certain children for particular types of work, and they hope that local education authorities will be prepared to adopt the suggestion that a list of such terms should be printed for use by the medical officer at the last routine examination of the children." It is interesting to note how with the passage of time the list of "unsultabilities" has increased. Sir George Newman first listed 9 then, when Form E.D.211 was used, the number had increased to 13. Now, the present form (Y.9) which displaced the E.D.211, lists 17. Some of the limitations to employment are heavy manual work, sedentary work, exposure to bad weather, work in damp atmosphere, work in dusty atmosphere, work involving normally acute vision, work involving normal colour vision. Any necessary investigations and treatment are carried out before a pupil leaves school. In addition to the Form Y.9 a letter is also sent to the Youth Employment Officer amplifying the information given on the form It is found in practice that limitations are most frequently recommended on account of eye stain and defective vision; next in order of frequency are heavy manual work, exposure to bad weather, prolonged standing, much walking or quick movement from place to place, and work in damp or dusty atmosphere. Following the passing of the Disabled Persons (Employment) Act, 1944, the Minister issued a Memorandum dealing with choice of employment for handicapped children. A form was issued (Y.10) which listed the same 17 unsultabilities mentioned in the gBneral schoolleaving medical report and, in addition, a section for recording the nature of the child's disablement, its probable duration, and its bearing on the obtaining or keeping of suitable employment. The essential difference between this form (Y.10) and the Y.9 is that the former contains a section for signature, in appropriate cases, by the parent or guardian and reads as follows "I agree that this report may be sent to the Youth Employment Service. I understand that the report will be treated as confidential, but that it may be disclosed, if necessary, to members of a Disablement Advisory Committee, or Panel thereof, if application is made for registration under the Disabled Persons (Employment) Act, 1944," This form is used mainly for children in attendance at the Special Schools, which are visited each term for the purpose of reviewing the capabilities of the school leavers. 141 Three years ago the Central Youth Employment Executive issued a brochure entitled The Youth Employment Service and Handicapped Young People. The booklet describes how the youth employment officers and the disablement officers of the Ministry of Labour and National Service can best collaborate, and co-operate with all other interested organisations and agencies to help handicapped young persons. It also discusses the advantages of registration under the Disabled Persons (Employment) Act, 1944. During the year 9 reports were submitted for this purpose. The great majority of children subject to limitations for certain occupations have the general form used for which no parental consent is required. MISCELLANEOUS Among other types of examinations may be mentioned the following (a) Medical examinations of children boarded out in foster homes or in the Children's Homes are carried out for the Children's Officer by medical officers of both the School Health Service and Maternity and Child Welfare Services. So far as practicable each of the children's Homes has a medical officer attached to it to take a personal interest in the welfare of the children and to give the occasional services required. During the year the medical officers of the School Health Service examined 55 children in the school clinics. (b) Medical examination of children prior to participating in school Journeys - 320; 24 relnspections; all were found fit. (c) Examinations by medical officers and nurses in connection with the Children's Country Holiday Fund - 106, 1 found unfit. (d) Medical examinations of children in connection with the Committee's Holiday Camps - 431; 423 relnspections; 1 child was found unfit. (e) Medical examination of boys prior to engaging in boxing bouts - 4-33; 2 were found unfit to box. In addition, certain children brought before the Juvenile Court, are submitted by the Children's Officer for physical examination. The medical officers also examine entrants to the Council's service and applicants for admission to the superannuation scheme as well as duties in connection with the Council's Protracted Sickness Scheme. Finally, the medical officers carry out examinations for fitness of teachers, college students and nursery students. Candidates applying for admission to training colleges and university departments are examined and a report on Form 4 R.T.C. completed for sending to the appropriate college or university authority. Entrants to the profession completing an approved course of training are medically examined and a Form 28 R.Q. completed for sending to the Ministry of Education. In these cases an x-ray examination is compulsory. The Ministry of Education Circular 249, 1952, sets out the above requirements. Teachers entering the service of the Council from other authorities are also examined as to their fitness for employment. 142 APPENDIX X. CAUSES OP DEATH IN AGE GROUPS - 1956 (as supplied by Registrar-General). Causes of Death All Ages Deaths at different periods of life of residents (civilians) whether occurring within or without the district. Under 1 Year 1-4 Years 5-14 Years 15-24 Years 25-44 Years 45-64 Years 65-74 Years 75 and upwards M F M F M F M F M F M F M F M F M F 1. Tuberoulosis, respiratory 11 - - - 1 - - - - - 1 - 5 - 4 - - - 2. Tuberoulosis, other - 2 - - - 1 - - - - - 1 - - - - - - 3. Syphilitic disease 5 4 - - - - - - - - - - - 1 1 2 4 1 4. Diphtheria - - - - - - - - - - - - - - - - - - 5. Whooping Cough 1 - 1 - - - - - - - - - - - - - - - 6. Meningococcal infections 2 - 1 - 1 - - - - - - - - - - - - - 7. Acute poliomyelitis - - - - - - - - - - - - - - - - - - 3o Measles - - - - - - - - - - - - - - - - - - 9. Other infective and parasitic diseases 2 2 - 1 - - - - • - 2 - - - - 1 - - 10. Malignant neoplasm, stomach 42 24 1 1 16 6 12 7 13 10 11. Malignant neoplasm, lung, bronchus 74 9 - - - - - - - - 2 - 47 6 17 2 8 1 12. Malignant neoplasia, breast - 36 - - - - - - - - - 4 - 17 - 8 - 7 13. Malignant neoplasm, uterus - 11 - - - - - - - - - 1 - 5 - 3 - 2 14. Other malignant & lymphatic neoplasms 78 57 - - - - - - - 2 4 4 21 11 39 23 14 17 15. Leukaemia, aleukaemia 2 5 - - - 1 - - - 1 - - 1 1 1 2 - - l6. Diabetes 7 9 - - - - - - - - 2 - 1 2 3 - 1 7 17. Vascular lesions of nervous system 90 137 - - - - - - - - 3 3 18 20 23 47 46 67 l8. Coronary disease, angina 151 92 - - - - - - - 1 6 1 57 18 54 34 34 38 19. Hypertension with heart disease 16 21 - - - • - - - - - - 5 3 4 8 7 10 20. Other heart disease 97 173 - - - - - - - - 1 10 13 17 21 22 62 124 21. Other circulatory disease 30 37 - - - - - - - - - - 9 8 8 12 13 17 22. Influenza 7 2 - - - - - - - - - - 2 - - 1 5 1 23. Pneumonia 65 40 7 3 1 2 - - - - - - 2 2 27 10 27 23 21. Bronchitis 96 48 - - - - - - - - 1 • 33 10 38 16 24 22 25. Other diseases of respiratory system 14 8 1 « - - - 1 1 - 1 - 6 1 4 3 1 3 26. Ulcer of stomach and duodenum 9 3 - - - - « - 1 - 1 - 3 - 1 2 3 1 27. Gastritis, enteritis and diarrhoea - 3 - - - - « - - - - - - 1 - - - 2 28. Nephritis and nephrosis 12 2 - - 1 - - - - - 2 - 5 2 2 - 2 - 29. Hyperplasia of prostate 9 - - - - - - - - - - - 1 - 1 - 7 - 30. Pregnancy, childbirth, abortion - 3 - - - - - - - 1 - 2 - - m - - - 31. Congenital malformations 6 4 4 3 - - - - - - - - 2 1 - - - - 32. Other defined and ill-defined diseases 62 76 22 18 - 1 « 1 - 1 5 5 13 9 15 20 7 21 33. Motor vehicle accidents 17 3 - - 1 - 1 - 5 - 4 - 3 2 2 1 1 - 34. All other accidents 18 13 2 - - - 2 - 1 1 5 1 5 2 1 3 2 6 35. Suicide 15 5 - - - ~ - - - 1 1 - 8 2 4 1 2 1 36. Homicide and operations of war 1 1 - - 1 - - 1 - ~ - - - - - - - - TOTAL (All causes) 939 830 38 25 6 5 3 3 8 8 43 33 276 147 282 228 283 381 143 APPENDIX II. Particulars of Bodies Received into the Mortuary. During 1956. Month Number Received Males Females Over 5 years of age Under 5 years Sent in by the Coroner Sent In by the Police Sent in for Sanitary Reasons No. of Post-Mortem Examinations held No. of inquests held No.of Bodies temporarily embalmed January 44 25 19 39 5 35 9 - 44 4 - February 42 22 20 39 3 39 3 - 42 3 5 March 32 13 19 29 3 28 4 - 32 8 7 April 21 9 12 20 1 20 1 - 21 4 1 May 34 25 9 34 - 26 8 - 34 7 6 June 25 14 11 23 2 20 4 1 24 10 4 July- 18 11 7 15 3 16 2 - 18 3 6 August 22 12 10 22 - 18 4 - 22 3 1 September 13 9 4 12 1 12 1 - 13 2 4 October 22 12 10 20 2 17 5 - 22 4 4 November 35 24 11 33 2 30 5 - 35 8 5 December 30 19 11 30 - 23 7 - 30 5 3 TOTAL 338 L__ 195 143 316 22 284 53 1 337 6l 46 144 APPENDIX III STATISTICS RELATING TO SCHOOL HEALTH SERVICE COMPARISON OF CERTAIN TYPES OP WORK CARRIED OUT IN THE YEARS 1953,1954,1955 and 1956. School Population: 1953: 29,653 1954: 29,707 1955: 29,487 1956 29,453 Number of cases dealt with TYPE OF WORK 1953 1954 1955 1956 Periodic Medical Inspections 9,032 9,110 8,072 7,593 Special Inspections and Relnspectlons 16,265 14,463 12,088 12,760 Uncleanllness Inspections by school nurses 58,296 68,839 68,934 63,787 Percentage of children found unclean 4.6 2.95 2.59 1.55 Minor ailments treated at the school clinics 3,888 3,145 2,342 2,542 Attendances at minor ailment clinics 20,132 18,760 17,751 15,638 Tonsil and adenoid operations known to have been performed 228 451 248 311 Orthopaedic defects known to have been treated at hospital orthopaedic clinics 192 172 118 115 Orthopaedic defects treated at the Council's physiotherapy clinics 114 96 111 126 Cases treated at the light clinics 190 182 185 218 Admissions to West Ham Open Air School, Fyfield Relnspectlons at West Ham Open Air School, Fyfield Reinspections of children on return from West Ham Open Air School, Fyfield 141 814 132 149 821 73 149 814 95 80 313 96 Children examined for employment 93 78 64 66 Children examined for entertainments 45 58 52 16 Children admitted to convalescent homes 119 104 146 106 Children found in need of speech therapy 91 58 78 50 Children referred for child guidance treatment 189 182 204 153 dental Work Children treated 5,468 4,701 5,009 4,050 Number of fillings: Permanent teeth. 886 2,162 5,205 5.234 Temporary teeth 250 1,329 2,613 2,052 Number of extractions: Permanent teeth l,4o8 1,054 1,245 1,263 Temporary teeth 5,903 5,702 4,762 4,077 Administrations of general anaesthetics 2,440 2,466 2,251 2,254 Other operations: Permanent teeth 3,318 1,312 3,693 4,259 Temporary teeth 2,651 544 1,189 768 Number of orthodontic cases treated 168 181 161 330 145 APPENDIX IV SCHOOL HEALTH SERVICE STATISTICS RELATING TO INSPECTION AND TREATMENT OP NURSERY, SPECIAL, PRIMARY, SECONDARY AND GRAMMAR SCHOOL PUPILS, 1956. TABLE I Return of Medical Inspection A. Periodic medical inspection: Code Group No.examined Entrants 1,956 Second Age Group 1,577 Third Age Group 2,547 Total: 6,080 Additional periodic inspections 1.513 Grand Total: 7,593 B. Other Inspections: Number of special inspections 7. 545 Number of reinspections 5,215 Total: 12,760 C. Pupils found to require treatment: Age Groups Inspected For defective vision (excluding squint) For any of the other conditions recorded in Table IIA Total individual pupils Entrants 5 106 109 Second Age Group 87 44 126 Third Age Group 132 57 183 Total 224 207 418 Additional periodic inspections 64 42 96 Grand Total 288 249 514 146 D. Classification of the Physical Condition of children inspected during the year in the Periodic Age Groups: Age Groups Inspected Number of pupils inspected Satisfactory Unsatisfactory No. % of Col. 2 No. % of Col. 2 (1) (2) (3) (4) (5) (6) Entrants 1,956 1,952 99.80 4 0.20 Second Age Group 1,577 1,575 99.87 2 0.13 Third Age Group 2,547 2,546 99.46 1 0.04 Additional Periodic Inspections 1,513 1,510 99.80 3 0.20 Total: 7,593 7,583 99.87 10 0.13 TABLE II Verminous Conditions (1) Total number of examinations of children in the schools by the school nurses 63.787 (2) Number of individual children found unclean 457 (3) Number of individual children in respect of whom cleansing notices were Issued 176 (4) Number of individual children in respect of whom cleansing orders were Issued 12 147 TABLE III Return of defects found by medical inspection in the year ended 31st December, 1956. Defect Code Number Disease or Defect Periodic No. of Inspections defects Special Inspections No. of defects Requiring treatment Requiring to be kept under observation Requiring treatment Requiring to be kept under observation 4 Skin 19 15 962 62 5 Eyes - (a) Vision 288 65 235 77 (b) squint 35 11 32 25 (c) Other 3 1 191 8 6 Ears - (a) Hearing 6 28 52 90 (b) Otitis media 2 3 32 10 (c) Other 1 3 89 4 7 Nose and throat 41 62 129 87 8 Speech 3 44 95 141 9 Lymphatic glands 1 4 2 9 10 Heart 2 28 22 72 11 Lungs 13 13 55. 58 12 Developmental - (a) Hernia 3 4 1 4 (b) Other 2 31 5 38 13 Orthopaedic - (a) Posture 24 12 15 29 (b) Plat feet 24 7 29 54 (c) Other 24 14 60 75 14 Nervous system - (a) Epilepsy 2 4 8 16 (b) Other 3 7 32 34 15 Psychological - (a) Development 1 4 59 101 (b) Stability 8 52 95 160 16 Abdomen 4 11 49 11 17 Other 29 88 1,668 366 19 Menstruation - - - - 148 TABLE IV Defects Treated Group 1. Diseases of the Eye, Defective Vision and Squint. Number of cases known to have been dealt with By the Authority Otherwise External and other, excluding errors of refraction and squint 173 24 Errors of refraction (including squint) - 1,483 Total: 173 1,507 Group 2. Diseases and Defects of the Ear, Nose and Throat Number of cases known to have been dealt with By the Authority Otherwise Received operative treatment (a) For diseases of the ear - 3 (b) For adenoids and chronic tonsillitis - 311 (c) For other nose and throat conditions - 3 Received other forms of treatment 153 247 Total: 153 564 Group 3. Orthopaedic and Postural Defects Number of cases known to have been dealt with By the Authority Otherwise (a) Number treated as in-patients in hospitals - - (b) Number treated otherwise, e.g., in clinics or out-patients departments 126 115 149 Group 4. Diseases of the Skin (excluding uncleanliness) Number of cases treated or under treatment during the year By the Authority Ringworm - (1) Scalp 1 (ii) Body 7 Scabies 14 Impetigo 78 Other skin diseases 843 Total: 943 Group 5. Child Guidance Treatment. Number of pupils treated at Child Guidance Clinics under arrangements made by the Authority 188 Group 6. Speech Therapy Number of pupils treated by Speech Therapists under arrangements made by the Authority 160 Group 7. Other Treatment Given Number of Cases Treated (a) Miscellaneous minor ailments treated by the Authority 1,273 (b) Pupils who received convalescent treatment under School Health Service arrangements 106 (c) Pupils who received B.C.G. vaccination 1,132 (d) Other than (a) (b) and (c) above Epilepsy and other conditions of the nervous system 24 Heart and circulation 1 Lungs 20 Other conditions not minor ailments 89 Total: 2,645 150 TABLE V Dental Inspection and Treatment (1) Number of pupils Inspected by the Authority's Dental Officers: (a) Periodic 5,375 3,6l1 (2) Number found to require treatment 6,263 (3) Number offered treatment 5,108 (4) Number actually treated 1,050 (5) Attendances made by pupils for treatment 16,661 (6) Half-days devoted to Periodic Inspection 11 Treatment 2,051 Total half-days: 2,095 (7) Fillings: Permanent teeth 5,231 Temporary teeth 2.052 Total fillings: 7,286 (8) Number of teeth filled: Permanent teeth 4,621 Temporary teeth 1.839 Total of teeth filled: 6,460 (9) Extractions: Permanent teeth 1,263 Temporary teeth 1,377 Total extractions: 5,610 (10) Administration of general anaesthetics for extraction 2,251 (11) Orthodontics: Cases commenced during the year 200 Cases carried forward from previous year 130 Cases completed during the year 19 Cases discontinued during the year 52 Pupils treated with appliances 188 Removable appliances fitted 175 Fixed appliances fitted 13 Total attendances 2,091 (12) Number of pupils fitted with artificial dentures 56 (13) Other operations: Permanent teeth 1,259 Temporary teeth 768 Total of "other operations": 5,027 151 INDEX Subject Page Adulterated samples 41 After Care 72-77,80 Ambulance Service 70,71 Analgesia 60 Ante-Natal and Post-Natal Care: facilities provided for 45,46 Appendices 1-4 143-150 Audlometrlc Surveys 108,109 Audlology Unit 51 Aural Clinics 107-109 B.C.G. Vaccination 69,114,115 Births 5,62 Blind Children 124-127 Blood Tests 46 Bronchitis 5 Cancer 5,14 Caravan Dwellers 37,39 Care of Mothers and Young Children 45-59 Chest X-ray - Expectant Mothers 46 Child Guidance 119-123 Child Health - Research and Investigation 99 Child Minders 53-55 Child Welfare 46-59 Clean Air Act, 1956 19-22 Cleanliness - School Children 98 Colour Vision 104-105 Condensed Milk 41 Committees, List of 3 Co-ordination of Maternity Services 6l Convalescence 55,56,138 Day Nurseries 53-55,77 Deaf Children 127 Deaths 5,47,57-58 Deaths - Causes and age groups 143 Delicate Children 130 Dental Treatment 115-116 Diphtheria 5,7,8 Diphtheria Immunisation 67-68 Disabled Persons (Employment) Act, 1944 141 Disinfection and Disinfestation 39,40 Domestic Help 78-79 Domiciliary Midwifery 60-62 Dried Milk 41 Drugs 42 Dustbins 36 Dysentery 5,7,9, Ear, Hose and Throat Clinics 107 Ear, Nose and Throat Defects, and defective hearing 107-109 Education Services - Liaison with 132 Educationally Sub-normal Children 128 Employment of children and young persons 139-140 I Subject Page Employment of School Leavers 94, 140-142 Elizabeth Pry Special School 133-134 Elizabeth Pry Spastic Unit 134 Epileptic Children 128-129 Epilepsy 90 Erysipelas 7,8 Factories Act, 1937 16-18 Fertilisers and Feeding Stuffs Act, 1926 42,43 Following-up (school children) 99 Food Hygiene Regulations, 1955 25-29,97 Food Inspection 22 Food Poisoning 5,7,9 Food Samples 23-25 Food Unsound 23 Foreign matter in articles of food 25 Fyfield OpeA-Air School 135 General Health and Welfare Services 88-90 Guardianship of Mental Defectives 85 Gurney Special School 133 Handicapped Children 52,53,95,124-136 Health Education 64,77 Health Visiting 63-64 Hearing of School Children 107-108 Heart Disease and Rheumatism 112-113 Home Nursing 65,66 Housing 31-35 Housing Repairs and Rents Act, 1954 32 Houses - Unfit 34 Houses - Defects remedied 35 Hygiene of School Premises 97 Ice Cream 24,25,42 Ice Lollies 25,42 Immunisation - Diphtheria 67-69 Impetigo 101 Infant Mortality 5,56-58,59 Infant Welfare 46-59 Infectious Diseases 5,7 Jelly Tests (Tuberculosis) for Children 48,49 Leavers (school) 94,140-142 Liaison 56 Lunacy and Mental Treatment Acts 83 Maladjusted Children 131 Malaria 7 Maternal Mortality 5,56,58 Maternity Outfits 60 Maternity and Child Welfare 45-59 Ante-natal and Post-natal Care 45 Audiology Unit 51 Blood Tests 46 Chest X-rays 46 Child Welfare 46-59 Convalescence 55,56 Day Nurseries and Child Minders 53-55 II Subject Page Dental Treatment 115-116 Handicapped Children 52,53 Health Visiting 63-64 Liaison with Children's Officers 56 Maternity Services 62 Midwifery 60-62 Perinatal Mortality 56 Physiotherapy 52 Premature Births 46,4-7 Specialist Clinics 49 Toddlers' Clinics 47 Toxaemia in pregnancy 6l Unmarried Mother and Child 46 Vitamin Intake in Infancy Survey 50,51 Welfare Poods 55 Maternity Services - Co-ordination of 6l Measles 5,7,8 Medical Inspection Rooms 96 Medical Inspection (school children) 91,146-150 Meningococcal Infection 5,7,8 Mental Deficiency 83-85 Mental Health 80-87 Mental Health Social Work 80,81,82 Midwifery 60-62 Milk, Samples taken 24,41,43 Minor Ailments (school children) 101-103 Miscellaneous Examinations 142 Mortuaries 144 Multiple Defects (school children) 132 National Assistance Act, 1948, Section 47 88-90 National Health Service Act, 1946 45-90,95 Neo-Natal Deaths 5,56 Nose and Throat Defects (school children) 107,109 Nursery Schools and Classes 136-138 Occupation Centre 85 Occupational Therapy 76 Ophthalmia Neonatorum 7 Ophthalmic Clinic 103-105 Orthopaedic and Postural Defects 110 Outworkers 18 Paediatrie Clinic 113-115 Paediatrlc Liaison 64 Partially Deaf Children 127 Partially Sighted Children 124-127 Perinatal Mortality 56 Physical Condition of School Children 92 Physically Handicapped Children 129 Physiotherapy 52,110-112 Pneumonia 5,7,8,10 III Subject Page Poliomyelitis 5,7 Poliomyelitis Vaccination 68 Population 5,6 Premature Infants 46,47 Prevention of Illness, Care and After-Care 72-77 Preservatives 4-2 Public Analyst, Report of 41-43 Publio Health - General Environmental - Defects remedied 35 Public Health Inspectors - Summary of Work 44 Puerperal Pyrexia 7,9 Pupil Midwives, Training of 6l Rag Flook 44 Refresher Courses-Midwives 60 - Health Visitors 64 Rehabilitation of Tuberoulous Patients 73 Relaxation Classes 60 Removal of Persons in need of care and attention 88-89 Research and Investigation 99 Rheumatism 112-113 Ringworm 100 Rodent Control 39-40 Sanitary Circumstances 16-44 Sanitary Inspectors; Work of - See "Public Health Inspectors" Sausages 24,29,30 Scabies 100 Scarlet Fever 5,7,8 School Dental Service 115-116,151 School Health Service 91-142,145-151 School Leavers and Employment 94 School Nurses, Work of 94 School Population 91 Senior Staff, List of 4 Short-term Care of Mental Defectives 85 Site and Area 6 Slaughterhouses 30 Smallpox 5,7 Smallpox Vaccination 67 Smoke Abatement 19 Spastic Unit 134 Special Schools 133-136 Speech Defects 117-119,131 Speech Clinics 118-119 Stillbirths 5,56,59 Supervision of Midwives 60 Swimming Baths 38 Throat Defeots 107,109 Toddlers' Clinios 47 Tonsillectomy 106 Toxaemia in Pregnancy 6l IV Subject Page Tuberculosis 5,7,11-12,72-75 After-Care 72-77 B.C.G.Vaccination 69,73,74,114,115 Convalescence 75,77 Deaths 5,12 Health Visitors 72 In Childhood 113 Jelly Tests for Children 48,49 Notifications 11-13 Rehabilitation 73,74 School Children 113,114 Typhoid and Paratyphoid 5,7,10 Uncleanliness 98 Unmarried and Mother and Child, Care of 46 Vaccination 67-69 Venereal Diseases 14,15 Visual Defects 103-105 Vital Statistics 5,6,56-58 Vitamin Intake in Infancy - Survey 50,51 Water Supply 16 Welfare Foods 55 Welfare and Health (General) Services 88-90 Welfare of School Children 93 West Ham Residential Open-Air School, Fyfield 135 West Ham School for the Deaf 135 West Ham Tuberculous Voluntary After-Care Committee 75 Whooping Cough 5,7,8 V